Patient Questionnaire

New Patient Questionnaire

Patient Information

Name(Required)

First Middle Last

Other Names

If you go by any other names, please share them here.

Home Phone(Required)

Cell Phone(Required)

Would you like to receive text reminders about future appointments?(Required)

Yes

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Date of Birth(Required)

Social Security Number(Required)

Sex(Required)

Female

Male

Other

Marital Status(Required)

Single

Married

Other

Primary Care Physician (PCP) Name(Required)

Employer Name

Employer Phone

Employer Address

Street Address Address Line 2 City State ZIP Code

Emergency Contact Information

Emergency Contact Name(Required)

Relationship(Required)

Home Phone(Required)

Cell Phone(Required)

Referral Information

How did you hear about us?(Required)

Return Patient

Doctor Referral

Internet

Other

Name of Referring Physician(Required)

Location of Practice(Required)

Additional Information

Date of Onset / Injury(Required)

Accident related?(Required)

Yes

What state did it happen in?(Required)

Work related?(Required)

Yes

Diagnosis / Body Part(Required)

Attorney involved?(Required)

Yes

Name of Attorney(Required)

Attorney Address(Required)

Street Address Address Line 2 City State ZIP Code

Attorney Phone(Required)

Have you had therapy before this year?(Required)

Yes

If yes, what reason or body part?(Required)

Medical History

Age(Required)

Height(Required)

Weight(Required)

Chief Complaint(Required)

How did this injury occur?(Required)

List any allergies to medications or food.(Required)

List any skin allergies. (ie. tape, sutures, betadine, latex)(Required)

Are you taking Coumadin?(Required)

Yes

Are you being treated for heart or lung problems?(Required)

Yes

Please explain condition or treatment.(Required)

Please explain reason for visit.(Required)

Please check if you have any of the following conditions.

Please indicate any other conditions you'd like us to know about.(Required)

Do any members of your family have a history of these conditions?(Required)

Yes

Please explain.(Required)

Previous Surgery Dates(Required)

Any complications with surgery or anesthesia?(Required)

Yes

Please explain.(Required)

I, the undersigned, have reviewed the above questions and have answered this information to the best of my knowledge. I believe these answers to be true, correct, and complete.

Signature(Required)

Medications

Let us know the medications you are currently taking. To add more than one, please use the plus icon on the right to add additional medications in this section.

Medication(Required)

Medication Name

Dosage

Frequency

CORE Policies

I have reviewed my medical history to include medications and prior surgeries and have this information to the best of my knowledge. I believe these answers are correct and complete.

I have received and reviewed the NOTICE OF PRIVACY PRACTICES (HIPPA) and understand information will be disclosed to others who assist in my care such as my spouse, significant other, children or parents and will allow information to be left on answering machine or email (when available.)

I understand that co-payments and out-of-pocket payments are due at the time services are rendered.

I hereby AUTHORIZE PAYMENT directly to Center for Orthopedic Rehabilitation (CORE) for medical benefits if any, otherwise payable to me for services rendered. I understand that I am financially responsible for charges not covered by my insurance carrier and agree to pay all the required deductible and co-insurance payments required by the policies of my insurance coverage.

I hereby authorize the undersigned physical therapists to RELEASE MEDICAL INFORMATION acquired in the course of my treatment to the insurance company or any party involved in reimbursement for the claim.

I request payment of authorized MEDICAL BENEFITS (if applicable) to be paid to Center for Orthopedic Rehabilitation on my behalf for services furnished to me. I authorize MEDICAL INFORMATION RELEASE about me be released to HCFA and/or its agents any information needed to determine these benefits or the benefits payable for related services.

Please note that cancellations of scheduled visits require 24 hour notice. If you are unable to provide this, you may be subjected to a $25 cancellation fee.

Signature(Required)

Patient Responsibilities

Please read and sign.

Referrals & Prior Approvals (if applicable): I understand my insurance company will not reimburse for the cost of today's services without a referral or prior approval and I am responsible for the payment of the office visit charge and/or any other charges I may incur.

CORE is now asking patients to keep a credit card on file with the office. If you wish to do this, please provide the card to the desk staff and it will be scanned into your personal secure chart. Before any balance is paid, a CORE staff member will call you with the amount due to receive verbal confirmation it is OK to run your card on that date.

If you agree, please initial here.(Required)

Deductible (if applicable): I understand that I have a calendar year/ plan year deductible for outpatient therapy as outlined in my insurance policy. I understand that I am responsible for any balances that my insurance company does not cover but has been applied to my deductible. CORE requires a payment of $50 per visit applied to your deductible balance. If you require assistance with this amount, please speak with the front desk staff.

Co-pay amount due each visit:(Required)

Co-pay (if applicable): I understand co-pay amounts are part of the agreement I have with my insurance company and are due at the time of each visit and that I am responsible for that payment.

Please write your deductible, the balance on your deductible as of today, and the amount to be collected at the time of your visit.(Required)

Co-insurance (if applicable): I understand that I have a co-insurance responsibility outline in my insurance policy and that I am responsible for any co-insurance balances as set forth by my insurance company.

Co-insurance percent:(Required)

Authorization to pay benefits to the provider: I hereby authorize payment directly to the provider for medical benefits and otherwise payable to me for services as described, realizing that I am responsible to pay for non-covered services.

Authorization to release information: I hereby authorize CORE to release any information acquired in the course of my examination or treatment to the insurance company or any other party involved in the reimbursement claim.

Medicare Patients ONLY - Lifetime Assignment of Medicare Benefits: I request that payment of authorized Medicare benefits be made to me or on my behalf to the above referenced Medical Practice for services furnished me. lauthorize any holder of medical information about me to release to the Health Care Financing Administration (HCFA) and its agents any information needed to determine these benefits or the benefits payable for related services.

Workers' Compensation information (if applicable): I understand that it is my responsibility to provide all workers compensation billing information at the time of my initial visit. I realize that without this information, I will be responsible for any charges incurred at the time of the visit. I understand that my health insurance information will be provided and benefits will be utilized in the event that my workers' compensation claim is denied.

Motor Vehicle Information (if applicable): I understand that it is my responsibility to provide all claim information associated with my motor vehicle accident at the time of the initial visit. I realize that without this information, I will be responsible for any charges incurred at the time of the visit. I understand that my health insurance information will be provided and benefits will be utilized in the event that my PIP is exhausted.

Please notify the front desk staff of any changes with your insurance during your treatment.

I have read and acknowledge the information given to me. I certify that the information given to me is true and correct to the best of my knowledge.

Signature