40:31 Physical Therapy and Fitness, PLLC

New Patient Intake

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Social Security Number *

Phone *

Email *

Address *

City *

State *

Postal code *

If patient is a minor, please enter guardian information below:

Full Name
Date of Birth
Phone Number

How would you like to receive invoices? *

How would you like to receive appointment reminders? *

When did your symptoms begin? *

Pain Levels (scale of 0-10) *

Current Pain
Highest Pain
Lowest Pain

Height & Weight *

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

Please enter all CURRENT medications and dosage below: *

Upload Driver's License Below *

Will You Be Using Insurance" (type YES or NO below) *

Attach PRIMARY Insurance Card (FRONT) *REQUIRED IF USING INSURANCE *

Attach PRIMARY Insurance Card (BACK) *REQUIRED IF USING INSURANCE *

Attach SECONDARY Insurance Card (FRONT)

Attach SECONDARY Insurance Card (BACK)

CONSENT FOR TREATMENT

I recognize that I am suffering from a condition requiring physical therapy services and treatment. I hereby consent to the rendering of physical therapy services by 40:31 Physical Therapy and Fitness PLLC

(40:31 PTF), as described to me or as my physician or 40:31 Physical Therapy and Fitness PLLC determines are necessary. I understand that the practice of physical therapy is not an exact science and that physical therapy treatment involves the risk of injury or even death. I acknowledge that no guarantees have been made to me about the outcome of treatment.

CONSENT OF DISCLOSURE

(For the Usage and/or Disclosure of Protected Health Information)

I hereby give consent to 40:31 Physical Therapy and Fitness PLLC and all health care providers furnishing care within 40:31 Physical Therapy and Fitness PLLC to use and disclose my protected health information for the purposes of treatment, payment, and health care operations. You may cancel this consent at any time. Your cancellation must be in writing, signed by you or on your

behalf, and delivered to the address listed above. This may be delivered in person or by mail, but will only be effective when actually received. Your cancellation will not be effective to the extent that others or we have acted in reliance upon this consent.

You have the right to request restriction on the usage and disclose of your protected health information for the purposes of treatment, payment, or health care operations. We are not required to grant your request, if we do, the restriction will be obligatory to us.

ASSIGNMENT OF INSURANCE BENEFITS

I hereby assign 40:31 Physical Therapy and Fitness PLLC (1) all insurance, Medicare, Medicaid, and other private or governmental benefits payable for my treatments and care; and (2) all rights to payment and all money paid for any claim related to physical therapy service and treatment. Anyone paying or receiving money for my benefits or claims shall pay the money directly to 40:31 Physical Therapy and Fitness PLLC for payments of my bills. I understand that I am financially responsible for all charges not

covered by my insurance or other third-party payers and that any balance after insurance or third party payment has been made is due within thirty (30) days.

I have read and understand this form and the program it describes, and I do voluntarily request the right to participate in treatment options provided by 40:31 Physical Therapy and Fitness PLLC. I do hereby discharge, release, and hold harmless 40:31 Physical Therapy and Fitness PLLC and any of their personnel participating in this rehabilitation program from any and all liability for damage of any kind or character resulting from any injury or condition that I may suffer, or may result from such treatment.

Please be advised that there are camera in multiple areas of this facility for liability and safety purpose. They are NOT in areas where there is a reasonable expectation of privacy (i.e. bathroom, private treatment rooms). If you have any questions or concerns, please ask to speak with management.

APPOINTMENTS

KINDLY GIVE AT LEAST 24 HOURS NOTICE FOR CANCELLATION OR RESCHEDULING. FAILURE TO GIVE 24 HOURS NOTICE WILL RESULT IN A $10.00 CHARGE. PLEASE BE TIMELY FOR APPOINTMENTS. If you arrive more than 15 minutes late for your scheduled appointment, you may have to reschedule. This is for the benefit of you and other patients being treated.

WHEN ABLE, PLEASE SCHEDULE YOUR APPOINTMENTS IN ADVANCE

TO ENSURE THE TIME THAT YOU NEED.

Appointment times given one week do not automatically follow through to the subsequent weeks.

The provider, patient, and receptionist have discussed the importance of frequency and duration.

HIPPA NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGEMENT OF RECEIPT

I have reviewed the Notice of Privacy Practices of 40:31 Physical Therapy and Fitness PLLC and understand that any questions or concerns regarding this notice may be directed to 40:31 Physical Therapy and Fitness PLLC’s staff. If I choose to, or are not able to sign, a staff member will sign and date this acknowledgement for me. This acknowledgement will be filed in my records.

By signing below, I acknowledge that I have read all of the information provided above (consent for treatment, consent of disclosure, assignment of insurance benefits, cancellation policy, and HIPAA) and I agree to the terms. By signing below, I am also stating that I have provided medical history to the best of my knowledge. THESE FORMS HAVE BEEN EXPLAINED TO ME AND I SIGN THIS VOLUNTARILY.

Please Sign Below *

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40:31 Physical Therapy and Fitness, PLLC Financial Policy

Thank you for choosing 40:31 Physical Therapy and Fitness, PLLC! We are committed to your entire experience here being successful. You have a financial responsibility that obligates you to ensure full payment of your bill. All patients must complete and sign the entire patient registration packet before they see the Physical Therapist. 40:31 Physical Therapy and Fitness, PLLC (40:31 PTF) has designed this financial policy to prevent any surprises at the end of the patient’s care. It is your responsibility to make sure that you understand the information in this agreement. Please read it, ask

us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.

Insurance: We need complete and accurate information about your policy. We must obtain a copy of your driver's license or valid photo id and current valid insurance to provide proof of insurance. This would include both primary and secondary insurances. If you fail to provide us with the correct insurance information in a timely manner, you will be responsible for the balance of a

claim. Knowing your insurance benefits is your responsibility. As a courtesy, 40:31 PTF will call the provided insurance company to verify eligibility and benefits. However, this will not be a guarantee of eligibility and benefits. Please contact your insurance company with any questions you may have

regarding your coverage.

In-Network: In the event that we are in-network with your insurance policy, you are responsible for meeting the in-network deductible before your insurance will pay for services rendered. You are responsible

for co-payments and/or coinsurance as specified in your “Explanation of Benefits”. 40:31 PTF has agreed with your insurance company to accept the Preferred Provider maximum allowable charge as full payment of the services rendered. You are responsible to pay for any services that are received but not covered under your policy. Co-pays, coinsurance or deductibles are due at the time of service.

Out-of-Network: In the event that we are out-of-network with your insurance policy, you are responsible for meeting the out-of-network deductible before your insurance will begin to reimburse for the services rendered. You are responsible for co-payments and/or coinsurance. You are also responsible for the difference between billed charges and your insurance company’s maximum allowable charges. Your out-of-network benefits for outpatient physical therapy should be explained in your insurance policy’s “Explanation of Benefits”. 40:31 PTF requires a minimum of $50 per session for patients who have an out-of-network insurance policy.

Uninsured Patients: Fee-for-service is exclusively a non-insurance financial arrangement. The Fee-for-service arrangement is exclusively separate from the In-Network and Out-of-Network scenarios. Fee-for-service receipts cannot be submitted to insurance for reimbursement. Payment is due in full at the time of each session.

Co-payments, coinsurance and deductibles: All co-payments, co-insurance, and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments, coinsurance and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment and/or coinsurance at each visit.

Non-covered services: Please be aware that some of the services you receive may be non-covered or not considered reasonable or necessary by your insurance company. Also, most insurance companies do not pay for medical supplies (such as exercise equipment, braces and/or therapeutic supplies). Our therapists are aware of the general payment practices of the major insurance

companies we are contracted with. However, as companies are continually refining their payment guidelines, 40:31 PTF cannot be held responsible for any payment practices your insurance company has set forth. You must pay for these services in full at the time of each visit. Or, inform us that you would not like to participate prior to receiving services.

Personal injury, liability, auto, or involvement of an attorney: You need to complete and sign all of the patient registration forms. We are required to obtain specific information about the involved insurance policies. You must provide us a copy of your personal insurance card. If you do not

provide the necessary information, we will only be able to provide care on a self-pay basis. We may also need a physician’s written referral for these cases. We may file claims with your personal health insurance policy and provide you with adequate documentation to file with other carriers. If your

personal insurance policy denies the claim for any reason, you are responsible for the full payment of your bill. In the event that 40:31 PTF carries a service balance due to active litigation, a judgment will be placed on the responsible party through the appropriate court system. You will be asked to sign a payment agreement prior to treatment being provided.

Minors: A parent or legal guardian must accompany the minor patient at the time of the initial visit. The parent or legal guardian is responsible for full payment as outlined in this financial policy. If the parents are separated and both legally responsible for the child, you must provide complete information from both parents. The parent or legal guardian that accompanies the minor patient to the clinic will have full responsibility for the payment should any dispute arise.

Claims Submissions: We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

Coverage Changes: If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If you do not notify us of the change in insurance, you will be responsible for the full amount of the claim. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you.

Payment Collection: Payment for services must be rendered in a timely manner. Please be advised that full payment is due AT THE TIME OR SERVICE. 40:31 PTF sends monthly patient statements to the address you provided. If payment has not been made if full 90 days from START of care, your account will be turned over to a collection agency.

Nonpayment: If your account is over 90 days past due with nonpayment, your account will immediately be sent to collections. Partial payments will no longer be accepted at this time.

Payment options: We accept Visa, MasterCard, Care Credit, checks and cash. All returned checks are subject to a $40.00 service charge.

ATTENDANCE: Our policy is to charge $10.00 for missed appointments not canceled within 24 HOURS of appointment time. These charges will be your responsibility and billed directly to you. This is NOT covered by insurance. After 2 consecutive NO-SHOWS or cancelations all remaining

appointments will be deleted from the schedule. At that time, it will be your responsibility to call to get yourself back on the schedule. Please help us to serve you better by keeping your regularly scheduled

appointment.

Refunds: Overpayments are refunded to the appropriate party, normally the insurance

company or the guarantor. Patient refunds will not be processed until all active or past due accounts are paid in full and all insurance claims have fully processed. Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.

I have read and understand the payment policy and agree to abide by its guidelines:

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