PATIENT CONSENT FORM

Date: ___/___/______
PATIENT CONSENT FORM
For therapy services through Orthopedic & Sports Physical Therapy Inc.
Please Print
Patient Name: ____________________________________
First
MI
Last
Date of Birth: _______/_______/_______
SSN __________-_________-__________
Home Phone #: _____________________
Mailing Address__________________________________
Cell Phone #: _______________________
_________________________________________________
Work Phone #: _____________________
City
State
Zip Code
check if above is billing address
Email Address: ___________________________________________
_____ Is it okay to email and/or text appointment reminders?
Emergency Contact(s): _____________________/__________
(If minor – list parent(s)/guardian(s)) Name & Relationship
e-mail only
text only
Phone #: __________________________
Cell #: __________________________
Can we discuss your condition with your emergency contact: _____ Yes
_____ No
Referring Physician and/or Primary Physician: _________________________________________________
Insurance Policy Holder/Billing Address (if different from above):
Name: ______________________________________
Date of Birth: __________________
____________________________________________________________________________________________
Address
City
State
Zip Code
Policy Holder’s Phone #: ___________________
Please read and provide consent:
1.
I, the patient above, (or _____________________________________for the patient), do hereby
voluntarily consent to medical treatment deemed as appropriate by the physical therapist and/or as ordered
by the above physician, their assistants, consultants, and as is necessary in his/her professional judgment.
2.
I authorize payment directly to Orthopedic & Sports Physical Therapy Inc. of the benefits otherwise
payable to me but not to exceed the regular charges for this period of treatment. If I have sought litigation
due to my injury and refuse to provide the appropriate insurance information, I understand that I am
required to pay Orthopedic & Sports Physical Therapy Inc. at the time services are provided. I also
understand that if I have filed a workers compensation claim and my claim is denied, I will then be
responsible for payment of services as they are received if I do not provide health insurance. I understand
that I am financially responsible to Orthopedic & Sports Physical Therapy Inc. for charges not covered by
my insurance.
3.
I hereby authorize Orthopedic & Sports Physical Therapy Inc., its employees or agents, to release
medical information regarding myself and my current condition to my insurance company for purpose of
payment and/or quality reviews; and referring, consulting, treating physicians, or other medical providers
as necessary to support continuity of care. This authorization will remain valid until revoked in writing.
4. I authorize the use of my records for physical therapy & office quality assessments to help provide
quality care. Research results do not identify individuals by name or any other personally identifying
characteristics. This authorization does not expire but may be revoked or limited in writing by me at any
time.
5. If appropriate I consent to the use of still photography and/or video analysis as a component of my
physical therapy evaluation at Orthopedic & Sports Physical Therapy Inc. I understand that the
Turn Over to Complete
photographs or videotape are part of medical record and cannot be reproduced or used in any other
manner, without my written consent.
6. I understand that I am responsible for checking with my insurance company regarding any co-pays,
deductibles or provider information that pertain to my treatment at Orthopedic & Sports Physical Therapy
Inc. Physical Therapy services are billed as free standing clinic setting.
Insurance Benefits (Please Read Carefully):
Your insurance is a contract between you and your insurance company.
Because of privacy laws, we are unable to obtain details of your specific coverage including deductibles, copays, co-insurance, your financial responsibilities and pre-authorization requirements. Only you can obtain
this type of information by either calling the customer service number on the back of your insurance care or
by checking with your employer’s benefits department.
Your health care provider, insurer, or plan may require a physician referral or prior
authorization and you may be obligated for partial or full payment for any therapy services
rendered.
It is critical that you check to determine if there are any pre-authorization requirements before completing
therapy. Please contact the front desk if we have any responsibility in this process. We will be glad to follow
through with any requirements. By double-checking on this, maximum benefits will be paid by your
insurance, which will reduce your financial responsibility.
Please initial:
_______
I understand that I am responsible for canceling any appointments 24 hours ahead of time;
otherwise there is a $30 charge. If I do not show up for 2 consecutive appointments without
calling, then future existing appointments will be cancelled. The Cancellation/No Show
Policy is attached for your information.
_______ Please initial that you have received the HIPAA information (Notice of Privacy Practices) that is
attached for your record. The notice describes how medical information about you may be
used. Please review it carefully.
Due to HIPAA and confidentially, please read and check the following as appropriate.
_____ I agree to the release of my medical or other information in order to process my insurance claims.
____ I am a self-pay patient, and I choose not to share any information with my insurance provider.
_____ It is okay to speak with or leave messages regarding your appointments with anyone at your home,
including on your answering machine.
_____ It is okay to speak with or leave messages regarding your appointments with anyone at your work.
Is there anyone that you do not want us to leave a message with regarding appointments? Yes
If Yes, list names:
No
________________________________________________________________________________________________
I have read this form and certify that I understand its contents as of this date and time. I agree that this
form is valid for up to 1 (one) year from the signed date.
________________________________________________________________________________________________
Signature of Patient
Date
________________________________________________________________________________________________
Guardian or Witness of minor
Date
C:\Program Files (x86)\neevia.com\docConverterPro\temp\NVDC\80ECBD80-3E08-4866-8B47-6F4D6EBB4D6B\Patient Consent Form 08-14.docRevised 06/2014 LS