Patient Name:

Date

Date of birth

Select

Male

Female

Address

City

State

Postal code

Community/development where you reside

Is this your Primary Billing Address:

Yes

Home Phone *

Mobile:

Email Address *

Referring Physician Name:

Mobile:

Primary Care Physician Name:

Mobile:

If you selected Word of Mouth or Other please provide the name of the person who referred you or specify how you found us:

BILLING INFORMATION

Please be aware our staff is fully comprised of independent contractor workers (1099) and they only get paid when they see someone. Please keep in mind that cancellations and no-shows can negatively affect these workers. Thank you!

Primary Insurance Information

Insurance Name

Subscriber Name

Member ID#

Relationship to Subscriber:

Secondary Insurance Information

Insurance Name

Subscriber Name

Member ID#

Relationship to Subscriber:

Zidell Physical Therapy

MEDICARE REGULATION DISCLOSURE

Medicare regulations require us to make you aware of our billing procedures and your financial responsibility. Zidell Physical Therapy accept Medicare Assignment for skilled physical and occupational therapy. Medicare will pay 80% of the reimbursable service charges. We will bill your co-insurance for the remaining 20%. If you do not have a secondary insurance or if your secondary insurance does not pay, we will bill you directly for the balance. I have received the policy statement, and have read and agree to the policies therein.

Patient Signature

Clear

Date

Patient Emergency Contact Consent

I authorize Zidell Physical Therapy to communicate directly with the following individual in regards to my health care:

Emergency Contact Name

Date

Telephone

Consent *

I have stated all known medical conditions on the Patient Intake Form. I have consulted a medical doctor or licensed medical health care practitioner regarding any checked or described conditions. I realize it is solely my responsibility to keep Zidell Physical Therapy and the attending therapist updated on any changes in my physical health and I understand that Zidell Physical Therapy and the practitioner shall not be liable should I fail to do so.

I understand that although skilled care will be provided throughout the treatment process, certain risks do apply. These risks include, but are not limited to, injury to muscles, tendons, bones; elevated heart rate, blood pressure and respiration rate. By signing this release, I hereby waive and release Zidell Physical Therapy and its therapists, from liability of injury excepting acts of negligence.

I understand Zidell Physical Therapy is obligated to abide by the Health Insurance Portability and Accountability Act (HIPPA) and understand the notice and how it relates to my personal information. Zidell Physical Therapy is required to provide you with a copy of our Notice of Privacy Practices which states how we may disclose/use your health information. I acknowledge that I have received a copy of Zidell Physical Therapy Notice of Privacy Practices. If I wish my medical information be shared with another party, I must provide written permission with exact names included.

I understand that I am financially responsible for all services rendered at Zidell Physical Therapy. All questions regarding fees should be asked prior to service. If my insurance changes, I am responsible for notifying Zidell Physical Therapy prior to my appointment, otherwise I will be responsible for the full payment of the visit. I understand that if my account balance is not paid in full, it may be forwarded to a collection agency. If any delinquent account balance is referred to a collection agency, I understand that I will be financially responsible for all costs relating to the collection of my debt.

Zidell Physical Theraphy

Servicing Palm Beach County On Site

Phone: 305-505-2565

PAST MEDICAL HISTORY FORM

Patient Name

Date

Please Check Any Applicable Conditions Either Current or Personal History

Briefly explain and give approximate date for all checked conditions. Also, include any surgeries and approximate dates. Indicate below any additional past medical history which has not been listed.

Have you had any fall in the past year?

YES

How Many?

Current Medications (please indicate prescription and non-prescription)

Medication

Dosage

Frequency

Route of Administration

Reason for Taking

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.