PATIENT INFORMATION
What is your full name?
___________________________________
Date of
birth______________________________________________
Address_________________________________________________
________________________________________________________
Home phone ________________ Work phone
___________________
Cell phone _______________ Doctor’s
Name ____________________
Diagnosis
________________________________________________
Marital Status: Single___ Divorced ___ Married ______
Spouse’s Name
___________________________________________
Spouse’s Work phone _____________Cell
phone ________________
Primary Insurance
_________________________________________
Policy Number _________________Group
Number ___________
Name of Subscriber ___________________
Relationship __________
Subscriber’s Date of Birth
_______________
Secondary Insurance
________________________________________
Policy Number __________________ Group
Number _______________
Employment/Accident/Workmen’s Comp:
______________________
Employer’s Address
________________________________________
Workmen’s Comp phone number
_____________________________
Contact person
___________________________________________
Responsible Party’s Employer
________________________________
Address
__________________________________________________
Emergency Contact (other than spouse)
________________________
Phone number
_____________________________________________
How did you hear about our clinic?
____________________________
Office use only:
Deductible _________ Deductible used by pt ______________
Copay _____________ Number of visits/year ______________
HEALTH HISTORY
Please check if you currently have or have
had any of the following:
___ Diabetes
___ Heart condition
___ High blood pressure
___ Mitral valve prolapse
___ Chest pain
___ Abnormal EKG/stress test
___ Orthopedic surgery
___ Problems with bones/joints affecting
ability to exercise
___ Cancer
___ Stroke
___ Pregnancy at this time
___ Parkinson’s
___ Seizures/fainting
___ Recent, unexplained weight loss
___ Neurological condition
___ Arthritis
___ Lung Disease, shortness of breath or
asthma
___ Other (explain)
_______________________________________
Medications:
____________________________________________
____________________________________________
Allergies:
_______________________________________________
I have read and completed this form:
Signature
___________________________ Date ______________
Phone (205) 298-9101 Fax (205) 298-9103
Consent for Physical Therapy Treatment
Authorization for Release of Information
Consent for Physical Therapy: I
hereby voluntarily consent to the rendering of care for a condition requiring
physical therapy services. I understand
that diagnosis and treatment may involve risks or injury. I acknowledge that no guarantees have been made
to me as a result of examination or treatment.
I hereby authorize Ellen Hamilton and Andrea Abercrombie, Birmingham Physical Therapy & Sports
Medicine, Inc, to retain any records for use, for research and for teaching
purposes.
Consent for Blood Testing: I
give my permission for a sampling of my blood to be tested for infectious
disease in the event that a therapist or other employee becomes exposed to my
blood or bodily fluid.
Authorization for Release of Information: I
authorize my referring physician to release any information necessary for my
treatment at Birmingham Physical Therapy
& Sports Medicine, Inc.
Medicare, Title XVIII:
The information that I have
given for payment application under Title
XVIII of the Social Security Act is correct. I authorize Birmingham Physical Therapy & Sports Medicine, Inc to release
any information to the Social Security or its carriers to gather information
needed to file this Medicare claim and request payment on my behalf.
Payment of Services:
I authorize any release of
medical information that is required for payment owed by me to Birmingham Physical Therapy & Sports
Medicine, Inc. I agree that Birmingham Physical Therapy & Sports
Medicine, Inc will not be responsible for confidentiality of any documents
released to any insurance carrier or other entity responsible for payment of my
healthcare costs. I authorize payment
from any third payer to be made directly to Birmingham Physical Therapy & Sports Medicine, Inc.
I understand that I am
financially responsible to pay all costs and fees to Birmingham Physical Therapy & Sports Medicine, Inc that are not covered by my insurance company. I agree to pay collection costs including
attorney fees incurred by Birmingham
Physical Therapy & Sports Medicine, Inc related to collecting costs and
fees charged to me for all services rendered and goods provided in the event of
failure to pay all debts.
We are committed to provide
the best service possible for you.
Please give us a 24 hour cancellation notice if you are unable to make
your scheduled appointment, so that we might notify other patients who may need
treatment.
Patient: __________________________________________ Date: _____________________
(Or signature of parent if
patient is a minor)
Witness:
__________________________________________
Date:
_____________________