New Patient Form

Please fill out this form before your first visit!

First Name

Last Name

Address

City

Postal code

State

Email *

Phone *

Date of birth

Gender

Have you been treated as a patient at Renewal Rehab before?

How did you hear about us?

Currently, How would you describe your overall health?

Would you be interested in more information regarding:

Would you like to receive email notifications on your physical therapy program, along with health and fitness updates?

Employer

Employer Address

Street Address
Address Line 2
City
State
Zip Code

Work Phone

Is this a work related injury?

Date of Injury

Responsible Party (if different from patient)

RESPONSIBLE PARTY (if different from patient): Address

Street Address
Address Line 2
City
State
Zip Code

RESPONSIBLE PARTY (if different from patient) : Home Phone

RESPONSIBLE PARTY (if different from patient): Cell Phone

RESPONSIBLE PARTY (if different from patient): Birth Date

RESPONSIBLE PARTY (if different from patient): Gender

RESPONSIBLE PARTY (if different from patient): Relationship

EMERGENCY CONTACT: Name

First
Last

EMERGENCY CONTACT: Address

Street Address
Address Line 2
City
State
ZIP Code

EMERGENCY CONTACT: Home Phone

EMERGENCY CONTACT: Cell Phone

How did your symptoms begin?

How often do you experience your symptoms?

How are your symptoms changing?

Getting Better

Not Changing

Getting Worse

During the past 4 weeks, Indicate the average intensity of your symptoms, 0 = None, 10 = Unbearable

During the past 4 weeks, How much has pain interfered with your normal work? (including both work outside the home, and housework)

Not at all

A little bit

Moderately

Quite a bit

Extremely

During the past 4 weeks how much of the time has your condition interfered with your social activities? (like visiting with friends, relatives, etc)

All of the time

Most of the time

Some of the time

A little bit of time

None

Who is your referring physician?

What treatment did you receive and when?

If Xrays were performed indicate the date

If CT Scan were performed indicate the date

If MRI were performed indicate the date

Were Other tests performed?

If Other test were performed indicate the date

Have you had similar symptoms in the past?

Yes

If you have received treatment in the past for the same or similar symptoms, who did you see?

MEDICAL HISTORY FORM: Physician Name

First
Last

MEDICAL HISTORY FORM: Diagnosis

MEDICAL HISTORY FORM: Are you presently working?

Yes

MEDICAL HISTORY FORM: Occupation

Do you have a history of Diabetes?

Yes

Do you have a history of Arthritis?

Yes

Do you have a history of back problems?

Yes

Do you have a history of high blood pressure?

Yes

Are you currently pregnant?

Yes

Do you have a history of: Cancer (Specify)

Do you have a history of: Lung Condition (Specify)

Do you have a history of: Seizure Disorder (Specify)

Do you have a history of: Heart Condition (Specify)

Do you have a history of: Infectious Disease (Specify)

Do you have a history of: Orthopedic Injuries (Specify)

Do you have a history of: Bleeding Tendencies (Specify)

Do you have a history of: Neurological Condition (Specify)

Do you have a history of: Psychological Condition (Specify)

Unusual Reactions to Hot or Cold (Specify)

Previous major hospitalizations / surgeries

List of prescription and over-the-counter medications

List of allergies

I have read and filled out the history questionnaire to the best of my knowledge.

I have read and filled out the history questionnaire to the best of my knowledge. (Date)

CONSENT FOR TREATMENT I do hereby agree and give my consent for Renewal Rehabilitation to provide medical care and treatment considered necessary and proper in treating my physical condition. SIGNATURE (Type your name)

FINANCIAL POLICY We have found that communication with our patients regarding financial policy assists in providing the best services to you. Please take the time to read the following before you sign. COMMERCIAL/ HMO/ PPO PLANS: Our staff is pleased to bill your insurance company as a courtesy to you after your benefits have been verified and authorization is obtained (if required by your plan). It is the patients responsibility to remit any deductible, co-pay, co-insurance or non covered charge amounts at the time of service. Should you choose to bill your own insurance, the billing office will provide you with an itemized list of services rendered during each appointment, however, full payment will be required at the time of each visit. If your insurance company fails to pay within 60 days of the date of billing, we will expect you to pay the balance of you bill and seek reimbursement from your insurance company. WORKERS COMPENSATION: All pre-authorized bills will be sent directly to the Workers Compensation carrier. In the event that your claim is denied, you will be responsible for payment. We will gladly file any other insurance carrier as a courtesy to you. MEDICARE: This is a Medicare certified facility and we will file claims directly to Medicare. You will be expected to notify us of any other forms of insurance which might be primary to Medicare for treatment being provided such as but not limited to Auto Insurance, Workers Comp., Group Insurance, Black Lung etc. In order to determine if another payer might be responsible, you will be required to complete a Medicare Questionnaire. SECONDARY INSURANCE: As a courtesy to you, we will file your supplemental carrier for you. Payment will be expected from you if you supplemental insurance does not pay your deductible, co-insurance or co-pays within 30 days of filing. PRIVATE PAY: Full payment is expected when services are rendered to continue treatment.

I have read and understand the FINANCIAL POLICY

Yes

AGREEMENT TO PAY I understand and agree that I am responsible and liable for payment of all charges assessed for professional services rendered. I have read and understand the financial policy detailed above. I understand that I am primarily responsible for all charges incurred regardless of my existing insurance coverage. In the event that my insurance forwards payment to me, I will deliver such payment to you. I understand that I am responsible for meeting my insurance deductibles, co-pays, co-insurance and non-covered services at the time of service. Should my account become past due, the balance becomes my responsibility and is immediately due and payable. In the event that my unpaid balance is referred for outside collections, I will be responsible for all collection and legal costs. My signature authorizes release of any medical information necessary to process my claim and assigns payment of benefits to Renewal Rehabilitation, Inc.

RESPONSIBLE PARTY SIGNATURE (Type your name)

Clear

Today's Date

I have read and understand the AGREEMENT TO PAY

Yes

Are you eligible to Medicare?

Yes

NOTICE OF PATIENT INFORMATION PRACTICES Effective Date: April 14, 2003 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO INFORMATION. PLEASE REVIEW IT CAREFULLY. Renewal Rehabilitation, Inc. is required by law to protect the privacy of your personal health information, provide this notice about our information practices and follow the information practices that are described herein.

I have read and understand the NOTICE OF PATIENT INFORMATION PRACTICES

Yes

USES AND DISCLOSURES OF HEALTH INFORMATION Renewal Rehabilitation uses your personal health information primarily for treatment; obtaining payment for treatment; conducting internal administrative activities and evaluating the quality of care that we provide. For example, Renewal Rehabilitation may use your personal health information to contact you to provide appointment reminders, or information about treatment alternatives or other health related benefits that could be of interest to you. Renewal Rehabilitation may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies, and for emergencies. We also provide information when required by law. In any other situation, Renewal Rehabilitation policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization at any time. Renewal Rehabilitation may change its policy at any time. When changes are made, a new Notice of Information Practices will be posted in the waiting room and the patient exam areas and will be provided to you on your next visit. You may also request an updated copy of our Notice of Information Practices at any time.

I have read and understand the USES AND DISCLOSURES OF HEALTH INFORMATION

Yes

PATIENT’S INDIVIDUAL RIGHTS You have the right to review or obtain a copy of your personal health information at any time. You have a right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes. You may also request in writing that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. Renewal Rehabilitation will consider all such requests on a case by case basis, but the practice is not legally required to accept them.

I have read and understand the PATIENT'S INDIVIDUAL RIGHTS

Yes

CONCERNS AND COMPLAINTS If you are concerned that Renewal Rehabilitation may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact our practice manager at the address listed below. You may also send a written complaint to the US Department of Health and Human Services. For further information on Renewal Rehabilitations Health Information Practices or if you have a complaint, please contact the following person: Michael Anastasas, P.T. 613 S. Magnolia Ave. #2 Tampa, FL 33606 (813) 254.9475

I have read and understand the CONCERNS AND COMPLAINTS

Yes

PATIENT INFORMATION ACKNOWLEDGEMENT FORM I have received Renewal Rehabilitation’s Notice of Information Practices. I understand that Renewal Rehabilitation may use or disclose my personal health information for the purpose of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice. I also understand that Renewal Rehabilitation will consider requests for restriction on a case by case basis, but does not have to agree to requests for restrictions. I hereby consent to the use and disclosure of my personal health information for purposes as noted in Renewal Rehabilitations Notice of Information Practices. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.

Signature (Type your name)

Clear

Today's Date - Patient Acknowledgement Form

I have read and understand the PATIENT INFORMATION ACKNOWLEDGEMENT FORM

Yes