Online Form | Physical Therapy Associates

Patient Information

Name

Address

City

State

Zip

Home Phone Number

Mobile Number

Gender

Male Female

Status

Married Single Widowed Divorced

Social Security Number

Date of Birth

Work Phone Number

Referring Physician

Emergency Contact*

Emergency Contact Number*

Patient Employer Information

Employer Name*

Address

City

State

Zip

Occupation

Date of Injury

Contact Name

Work Related

Yes No

Primary Insurance Information

Insurance Carrier

Name of Insured

ID Number

Employer of Insured

Group Number

Date of Birth of Insured

Secondary Insurance Information

Insurance Carrier

Name of Insured

ID Number

Employer of Insured

Group Number

Date of Birth of Insured

Medical Information

Primary Care Physician

Last Visit With Physician

Main reason for visit today

Onset

Surgeries

Medication

List ALL current prescriptions, over the counter medications, herbal, vitamin/mineral/dietary (nutritional) supplements

MEDICATION NAME	DOSAGE (ex. mg,ml, cc)	FREQUENCY (ex. 3 times a day, 5 times a week)	ROUTE OF ADMINISTRATION (ex. oral, injection, topical)
		As needed Once daily Twice daily Three times daily Daily	Oral Sublingual Topical Injection Other
		As needed Once daily Twice daily Three times daily Daily	Oral Sublingual Topical Injection Other

DUE TO FEDERAL PRIVACY RULES (HIPPA) we cannot speak to anyone other than yourself regarding your treatment or bill without your consent. Please indicate the person(s) that you are authorizing us to release your personal protected health information to:

Person/s*

Relationship To Person/s*

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPPA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly or indirectly.
Obtain payment from third-party payers
Conduct normal healthcare operations such as quality assessments and physician certifications.

I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Private Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide in such restrictions.

I authorize my insurer to pay any benefits for services rendered directly to Physical Therapy Associates. I understand that anything not covered by insurance is my full responsibility. I hereby authorize Physical Therapy Associates through it’s appropriate personnel to perform on me, or the patient named above, appropriate assessment and treatment procedures relating to my diagnosis.

Initials*

Print Name*

Date*