New Patient Packet - Neurosport Rehabilitation Associates

WELCOME
Welcome to Neurosport Rehabilitation Associates. It is our goal to provide you with professional care and we
will make every effort to see that you have an excellent experience with us. If you have any questions or
concerns regarding your physical therapy, please feel free to discuss them with your therapists.
INSURANCE
As a patient receiving medical care, you should be aware of insurance coverage and limitations. We recommend
you check with your insurance to understand your coverage. You are responsible for the charges incurred
during your rehabilitation and as a courtesy; we will bill your insurance.
After all charges have been billed to your insurance, a statement will be sent to you if there is a balance
remaining. If you need a statement before that time, please contact our office.
APPOINTMENTS
In order to achieve your goals for recovery, regular attendance is necessary. Please check in at the front desk at
which time your copay will be collected. As a courtesy, we ask that you contact us if you are going to be late or
need to cancel. Please let us know at that time if you need to reschedule, if you will continue treatment at your
next appointment or if you feel you no longer require physical therapy services. If you cancel your appointment
with less than 24 hour notice or fail to show up for an appointment more than once, your future appointments
may be removed from the schedule. A $25.00 missed appointment fee may be charged.
I understand and agree to the above policy.
X_____________________________________________
Patient Signature
X_______________________________
Date
If you would like us to bill your insurance, please read and sign the statement below.
I authorize payment of medical benefits to Neurosport Rehabilitation Associates for physical therapy treatment.
This includes major medical benefits to which I am entitled including Medicare and other government sponsored
programs, private insurance, and any other health plans. I authorize the release of any medical or other
information necessary to process my claims. This assignment will remain in effect until revoked by me in
writing.
X_____________________________________________
Patient Signature
X_______________________________
Date
Informed Consent
Thank you for choosing Neurosport Rehabilitation Associates for your physical therapy. We
appreciate you and your physicians' confidence in our service.
It is our philosophy that treatment be based on a thorough biochemical and neurophysiological
evaluation. The results of the evaluation allow us to implement corrective treatment for your
condition. This assessment may include reflex testing, sensory testing, muscle testing, and
joint mobility/stability testing.
We will explain each step of the evaluation process. Should you become uncomfortable or the
procedure becomes painful, please let your therapist know. We will be happy to explain the
test function or modify the technique.
Once again, thank you for choosing Neurosport.
Respectfully,
The Staff of Neurosport Rehabilitation Associates
I have read and understand this information.
X____________________________
Patient Signature
X_______________________
Date
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how
you can get access to this information.
We are required by law to maintain the privacy of your protected health information and to
provide you with this Notice of Privacy Practices. We are also required to abide by the privacy
policies and practices that are outlined in this notice.
Uses and Disclosures of Your Health Information
Treatment: Your health information may be used by staff members or disclosed to other health
care professionals for the purpose of evaluating your health, diagnosing medical conditions,
and providing treatment. The results of your evaluation will be available in your medical
records to all health professionals who may provide treatment or who may be consulted by
staff members.
Payment: Your health information may be used to seek payment from your insurance. Your
insurance may request and receive information on dates of service, services provided, and the
medical condition being treated.
Health Care Operations: Your health information may be used as necessary to support the
day-to-day activities and management of the company. Information regarding the services you
received may be used to support budgeting and financial reporting, and activities to improve
quality.
Law Enforcement: Your health information may be disclosed to law enforcement agencies,
without your permission, to support government audits and inspections, to facilitate law
enforcement investigations, and to comply with government mandated reporting.
Public Health Reporting: Your health information may be disclosed to public health agencies
as required by law. For example, we are required to report certain communicable diseases to
the state’s public health department.
Other uses and disclosures require your authorization. Disclosure of your health information or
its use for any purpose other than those listed above requires your specific written
authorization. If you change your mind after authorizing a use or disclosure of your information
you must submit a written revocation of authorization. However, your decision to revoke the
authorization will not affect or undo any use or disclosure of information that occurred before
you notified us of your decision.
Additional Uses of Information
Appointment Reminders: Your health information will be used by our staff to send you
appointment reminders.
Information About Treatment: Your health information may be used to send you information
on the treatment and management of your medical condition or new technology that you may
find to be of interest. We may also send you information describing other health-related goods
and services that we believe may interest you.
Your Health Information Rights
You have certain rights under the federal privacy standards. These include:
► The right to request restrictions on the use and disclosure of your health information.
► The right to receive confidential communications concerning your medical conditions
and treatment.
► The right to inspect and copy your health information.
► The right to amend and/or submit corrections to your health information.
► The right to receive an accounting of how and to whom your health information has
been disclosed.
► The right to receive a printed copy of this notice.
Our Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy policies and
practices. These changes in our policies and practices may be required by changes in federal
and state laws and regulations. The revised policies and practices will be applied to all
protected health information that we maintain and will be available at our facility for you upon
request.
Requests To Inspect Protected Health Information
As permitted by federal regulations, it is required that requests to inspect or copy protected
health information be submitted in writing. You may obtain a form to request access to your
records from the front desk.
Complaints
If you would like to submit a comment or complaint about our privacy practices, or if you
believe your privacy rights have been violated, you can contact the company by sending a
letter outlining your concerns to:
Terry Toth
Neurosport Rehabilitation Associates
2296 Country Drive
Fremont, Ca 94536
You may also file a written complaint with the Office of Civil Rights.
Receipt of Notice of Privacy Practices
Patient Name:_____________________________________________________
Chart #:______________________________________
Date:_________________________________________
My signature on this form acknowledges that I have received and have access to a copy of
Neurosport Rehabilitation Associates' notice of Privacy Practices. I understand that this
document provides an explanation of the ways in which my health information may be used or
disclosed and of my rights with respect to my health information.
I have been provided with the opportunity to discuss concerns I may have regarding the
privacy of my health information.
X_______________________________
Patient Signature
X_______________________
Date
X_______________________________
Signature of Patient Representative
(if patient is unable to sign)
X_______________________
Date
To be completed by admitting clinician if above form is NOT signed
1. Was the patient provided with a copy of the agency's Notice of Privacy Practices? YES / NO
2. Briefly describe efforts made to obtain the patients acknowledgment of receipt of the notice
and explain why the patient was not able or willing to sign this form:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
X________________________
Signature of Admitting Clinician
X____________________
Date
Insurance
Welcome to Neurosport Rehabilitation Associates. It is our goal to provide you with
personalized and professional care during your period of rehabilitation. If you have any
questions or concerns regarding your physical therapy, please feel free to discuss them with
your therapist.
As a patient receiving medical care, you should be aware of your insurance coverage and
limitations. You are responsible for the charges incurred during your rehabilitation. As a
courtesy, we will bill your insurance. In order to do that you must provide the necessary
insurance information at the time of your first visit. If this information is not received, you will be
expected to pay in full for your visit or reschedule your appointment.
We will call your insurance to verify your copay and if any authorization is needed, however we
are not able to quote your benefits to you. It is your responsibility to check with your insurance
regarding your physical therapy benefits. A receipt will be given when any payment is made at
our office. If you do not receive one please request one, since this will be your proof of
payment.
If your insurance carrier does not remit payment within 90 days, the balance will be due and
payable by you. Accounts not paid within 30 days after the insurance has paid may be placed
in collection unless prior arrangements have been made with the patient account manager.
After all charges have been billed to your insurance company a statement will be sent to you if
there is a balance remaining. If for any reason you need a statement before that time please
contact our office.
I understand and agree to the above policy.
X________________________________
Patient Signature
X________________________
Date
If you would like us to bill your insurance, please read and sign the statement below.
I authorize payment of medical benefits to Neurosport Rehabilitation Associates for physical
therapy treatment. This includes major medical benefits to which I am entitled including
Medicare and other government sponsored programs, private insurance, and any other health
plans. I authorize the release of any medical or other information necessary to process my
claims. This assignment will remain in effect until revoked by me in writing.
X________________________________
Patient Signature
X_________________________
Date
Print
Clear Form
NAME: _________________________________________
DOB: ___________________________________________
DATE: __________________________________________
CHART#: _______________________________________
PATIENT HEALTH QUESTIONNAIRE
Age: ___________ Sex:
Male
Female Are You:
Right-Handed
Left-Handed
Who referred you to the Physical Therapist? _____________________________________________________________
Living Environment
Does your home have?
Stairs, no railing
Stairs, railing
Ramps
Elevator
Uneven terrain
Assistive devices (ex: bathroom): _______________________________________________________________________
Any Obstacles: ____________________________________________________________________________________________
Do you have support at home? Describe: __________________________________________________________________
Medical History
Please check if you have ever had:
Arthritis
Broken bones/ Fractures
Osteoporosis
Stroke
Allergies
Depression
High Blood Pressure
Hypoglycemia
Multiple Sclerosis
Diabetes
Thyroid problems
Parkinson disease
Heart Disease
Tuberculosis
Hepatitis
Cancer
Blood Disorders
Seizures/ Epilepsy
Circulation/Vascular problems
Asthma
Other: _______________________________________________________________________________________________________
Have you ever had surgery?
Yes
No
If yes please describe and include the dates:
________________________________________________________________________________________
______/______/______
________________________________________________________________________________________
______/______/______
NAME: ________________________________________
Current Condition(s)
Describe the problem(s) for which you seek physical therapy. __________________________________________
When did the problem(s) begin? ___________________________________________________________________________
What happened? _____________________________________________________________________________________________
Have you ever had the problem(s) before?
Yes
No
Use the picture below to show the location of
your pain/problem.
Rate your pain below
0
10
(No pain)
(Worst pain
you ever had)
How are you taking care of the problem(s) now? _________________________________________________________
What makes the problem(s) better? _______________________________________________________________________
What makes the problem(s) worse? _______________________________________________________________________
Are you seeing anyone else for this problem(s)? (ex: Chiropractor) ____________________________________
Is your problem causing difficulty with: (please check all that apply)
Bed mobility
Walking
Self-care (ex: bathing, dressing)
Chores
Care of dependents
Driving
Other: _______________________________________________________________________________________________________
Medications
Do you take any medications?
Yes
No
If yes, please list all or provide a list: _______________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
PatientHealthQuestionnaire_v1.1