Artemis Physical Therapy Patient Information

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1 Artemis Physical Therapy Patient Infrmatin Client Infrmatin Last Name First Name MI Address City Zip Date f Birth Female Male Emplyer (ptinal) Cntact Infrmatin Hme Phne Cell Phne Wrk Phne (ptinal) Emergency Cntact Name Emergency Cntact Phne Number Relatinship t Patient Health Care Team Infrmatin (Optinal) Prvider s Name Prvider s Name Prvider s Name Clinic Name/Cntact Infrmatin Clinic Name/Cntact Infrmatin Clinic Name/Cntact Infrmatin Hw did yu hear abut Artemis Physical Therapy? I understand that Artemis Physical Therapy, PLLC will maintain my privacy t the highest standards and may use r disclse my persnal health infrmatin fr the purpses f carrying ut treatment, btaining payment, evaluating the quality f services prvided and any administrative peratins related t treatment r payment. , VOIC and TET COMMUNICATION OPTION: I hereby give my cnsent fr the use f , vice and/r text messaging t cmmunicate abut my care at Artemis Physical Therapy, PLLC including pending appintments. I understand that such cmmunicatins may include persnal healthcare infrmatin and that such transmissins are nt encrypted. Such cmmunicatins are limited t me and parties with whm I give written permissin t cmmunicate. At n time will such cntact infrmatin be shared r publicized. I understand that I retain the right t revke this cnsent by ntifying the practice in writing at any time. I VERIFY THAT THE ABOVE INFORMATION IS ACCURATE Date Artemis Physical Therapy, PLLC P a g e 1 1

2 Artemis Physical Therapy Health and Wellness Infrmatin Sheet Yur current cnditin What is the primary issue that brings yu in tday? D yu have a secndary cncern? Please shade in areas where yu have pain, discmfrt, r tensin. As a result, I am nw having difficulty with : Are yu currently experiencing pain as a result f these symptms? If yes, please describe? When did yur symptm(s) begin? Rate yur symptms in the last hurs Using the 0-10 scale where 0 is n pain and 10 is the wrst pssible pain. At its wrst At its best At present While sleeping At what time f day are yur symptms the wrst? At what time f day are yur symptms the best? What activities increase yur pain? What activities decrease yur pain? What ther types f treatment have yu had fr this prblem? Massage Bdywrk Physical Therapy Medicatins/Injectins Chirpractic Surgery Other Medical Treatment: (Please Describe) Artemis Physical Therapy, PLLC P a g e 1 4

3 Artemis Physical Therapy Health and Wellness Infrmatin Sheet List imprtant activities yu are unable r have difficulty perfrming as a result f yur symptms r pain and indicate yur tlerance. If yu are n lnger able t perfrm an activity, yur tlerance wuld be 0. Activity Tlerance (minutes/hurs) I walk fr minutes befre needing t rest I stand fr minutes befre needing t sit I sit fr minutes befre needing t change psitins/get up D yu have truble getting up frm a chair? Yes N D yu have truble putting n yur shes and scks? Yes N D yu have difficulty climbing stairs? Yes N If sleep is a prblem, answer these questins: D yu have truble falling asleep? Yes N D yu find it difficult t change psitins in bed? Yes N Is yur sleep restful? Yes N Hw many times d yu wake in the night? D yu find it difficult t lie dwn? Yes N Hw lng befre yu fall back t sleep? D yu have any ther gals yu wuld like t reach? Artemis Physical Therapy, PLLC P a g e 2 4

4 Artemis Physical Therapy Health and Wellness Infrmatin Sheet Brief Medical Histry Check the bx if yu have been diagnsed any f the fllwing medical cnditins? Arthritis Brken Bnes Circulatin Prblems Diabetes Epilepsy /Seizures Heart Disease Heart Murmur High Bld Pressure Kidney Disease Liver Disease Lung Disease Malignancy Metal Implants Migraine Headaches Neurlgical Prblems Osteprsis Pacemaker Pregnancy Rheumatic Fever Strke Other: (please explain) Have yu RECENTLY nted any f the fllwing? (check all that apply) Changes In Bwel Or Bladder Functin Fever/Chills/Sweats Weakness/Fatigue Weight Lss/Gain Shrtness Of Breath Changes In Appetite Nausea/Vmiting Pain At Night Difficulty Swallwing Dizziness/Lightheadedness Headaches Other: (please explain) List any surgeries, accidents and ther traumas. List ALL medicatins which yu are currently taking, the cnditin fr which yu are using them, the dse, and their effectiveness. (Include supplements, herbal and hmepathic remedies). Medicatin Fr treatment f Dse / Amunt per day Effectiveness Artemis Physical Therapy, PLLC P a g e 3 4

5 Artemis Physical Therapy Health and Wellness Infrmatin Sheet Is there a chance yu may be pregnant at this time? YES NO List all allergies: Are yu latex sensitive? YES NO Are yu sensitive t adhesive bandages? YES NO Lifestyle D yu engage in regular exercise? YES NO What type and hw ften? Are yu able t exercise nw? YES NO D yu have discmfrt, shrtness f breath, r pain with exercise? YES NO Please Describe: In general, yur lifestyle is: Active Average Inactive D yu smke? YES NO If Yes -Hw Much? Is there anything else yu wuld like t share regarding yur cnditin, gals, medical histry r lifestyle? I hereby agree that the abve infrmatin is true t the best f my knwledge and will infrm Artemis Physical Therapy if my status changes. Date Artemis Physical Therapy, PLLC P a g e 4 4

6 Letter f Understanding fr Medicare-Eligible Clients Artemis Physical Therapy, PLLC is nt cntracted with Medicare r any ther frm f health insurance. Services rendered in ur practice are nt cvered by Medicare r yur Secndary Insurance. If yu wuld like Physical Therapy t be cvered by insurance and if yu have a Physician referral fr such we will be happy t prvide yu with alternative ptins. If yu are unwavering, hwever, in yur desire t be seen by Dr. Sally Mres fr her expertise, we ask that yu sign belw t indicate that yu understand that this is a nncvered service by Medicare and t understand that yu cannt receive reimbursement frm yur insurance prvider, secndary r therwise, fr this service. Dr. Mres des nt believe in discriminatin against clients wh are 65 and ver (ie, Medicare eligible) by turning them away if they wish t be seen by her, even thugh they have been given and cnsidered ther ptins that might be cvered by insurance. She wuld like t help yu and is willing t assess yur prblem and administer services deemed nt medically necessary by Medicare. These services may include, but are nt limited t massage therapy, wellness advice, preventative and fitness exercises. Hwever, because physical therapy has nt yet been included in Medicare pt ut legislatin, Dr. Mres is prhibited frm treating Medicare-eligible clients fr acute prblems, pst surgical treatment r any issues that are cnsidered cvered services. Actins are being taken t rectify this situatin thrugh the American Physical Therapy Assciatin s that there will nt be a questin abut whether yu can see a nn-medicare prvider Physical Therapist if yu wish. We wuld be happy t answer any questins yu have regarding this matter. Thank yu fr understanding I understand the Medicare-eligibility issue described abve and I am willing t pay privately t see Dr. Sally Mres (Artemis Physical Therapy, PLLC) fr services deemed nt medically necessary by Medicare, including, but nt limited t massage therapy, wellness, preventin and fitness services. By signing belw I acknwledge, under my wn free will and accrd, that I wuld like t restrict disclsure t my health plan by Artemis Physical Therapy fr the purpses f payment because I accept full ut-f-pcket financial respnsibility. Date Artemis Physical Therapy, PLLC P a g e 1 1

7 Artemis Physical Therapy Infrmed Cnsent Physical therapy is a patient care service that is prvided in rder t manage a wide variety f cnditins. Services are prvided t individuals f all ages regardless f gender, clr, ethnicity, creed, natinal rigin, r disability. The purpse f physical therapy is t treat disease, injury and disability by examinatin, evaluatin, diagnsis, prgnsis and interventin by use f rehabilitative prcedures, mbilizatin, manual therapy, exercises, aid the patient in achieving their maximum ptential within their capabilities and t accelerate cnvalescence and reduce the length f functinal recvery. All prcedures will be thrughly explained t yu befre yu are asked t perfrm them. Respnse t physical therapy interventin varies frm persn t persn; hence, it is nt pssible t accurately predict yur respnse t a specific mdality, prcedure, r exercise prtcl. Artemis Physical Therapy, PLLC des nt guarantee what yur reactin will be t a specific treatment, nr des it guarantee that the treatment will help reslve the cnditin that yu are seeking treatment fr. Furthermre, there is a pssibility that the physical therapy treatment may result in aggravatin f existing symptms and may cause pain r injury. It is yur right t decline any part f yur treatment at any time befre r during treatment, shuld yu feel any discmfrt r pain r have ther unreslved cncerns. It is yur right t ask yur physical therapist abut the treatment they have planned based n yur individual histry, physical therapy diagnsis, symptms, and examinatin results. Cnsequently, it is yur right t discuss the ptential risks and benefits invlved in yur treatment. Phtgraphs may be taken during initial evaluatin, prgress evaluatin and discharge summary. These will be used fr physical cmparisn purpses and as educatinal tls. By signing belw I cnsent t the use f these phtgraphs in a prfessinal manner. Cancellatin and N Shw Plicy It is required that all cancellatins ccur at least 24 hurs prir t yur scheduled appintment time. When yu schedule an appintment with Artemis Physical Therapy, yu make a cmmitment t yur health. In turn, we guarantee that time is reserved slely fr yu. Missed appintments can interfere with yur prgress in treatment. Als, when an appintment is missed withut cancelling within a 24 hur time perid, the physical therapist des nt have the pprtunity t ffer that time t smene else in need f services. T ensure that Artemis Physical Therapy best meets the needs f all, it is ur plicy that patients are respnsible fr all appintments they have scheduled. If yu d nt cancel prir t 24 hurs f yur appintment r yu d nt shw up fr yur appintment then the cst f the service will be charged t yur credit card. Yu will be asked t prvide a valid credit card when scheduling yur first appintment and that credit card will remain n yur accunt indefinitely. It is the respnsibility f the client t be n time fr their service and the entire fee fr the scheduled service will be charged even if the client is late and des nt receive the full treatment. This cancellatin plicy is fr all types f appintments. Extenuating circumstances and special situatins will be reviewed n an individual basis per the discretin f Artemis Physical Therapy. Payment Plicy Yur initial evaluatin is $140 and fllw-up treatment sessins are $112. Payment is due at the time f service. Payment, in the frm f cash, check r credit card, is due at the time f each visit. Artemis Physical Therapy values relatinships with patients nt insurance cmpanies. We d nt cntract with any insurance cmpanies. Hwever, the payments yu make may be reimbursable by yur insurance cmpany under yur ut-f-netwrk physical therapy benefits; the exact percentage depends upn yur plan. Due t the cmplex nature f insurance claims and reimbursement, Artemis Physical Therapy cannt guarantee as t whether yu will receive reimbursement. We will prvide yu with the dcumentatin necessary t submit reimbursement and will assist yu in every way pssible I have read this cnsent frm and understand the risks invlved in physical therapy and agree t fully cperate, participate in all physical therapy prcedures, and cmply with the established plan f care. I d hereby agree and give my cnsent fr Artemis Physical Therapy, PLLC t furnish care and treatment that is cnsidered necessary and prper in diagnsing and treating f my physical cnditin. I verify that I have read and understand the cancellatin/n shw and payment plicy Date Artemis Physical Therapy, PLLC P a g e 1 1

8 Artemis Physical Therapy, PLLC 15 Mystic Rd Marblehead, MA Patient Name: Date f Birth: Address: Date f Service: Next Appintment Date: City / State / ZIP Phne #: ICD-10/Diagnsis Cdes: License # MA PT Place f Service: # Office cde #11 Tax ID/EIN: Prvider Name Sally Mres, PT, DPT, OCS NPI: PROCEDURES CODE UNITS FEE TOTAL NOTES: Physical Therapy Evaluatin $84.00 $ Manual Therapy $28.00 $ Therapeutic Exercise $28.00 $ Therapeutic Activities $28.00 $ Neurmuscular Re-educatin $28.00 $ TOTAL: $ **PATIENT PAID BALANCE IN FULL** **Artemis Physical Therapy, PLLC is NOT an insurance Sally Mres, PT, DPT, OCS prvider fr this claim. ** **PLEASE PROVIDE PAYMENT DIRECTLY TO PATIENT.**

9 Hw t Determine Yur Out-f-Netwrk Insurance Benefits fr Physical Therapy 1. Call the tll free number fr custmer service n yur insurance card. Select the ptin that will allw yu t speak with a custmer service representative, nt an autmated system. 2. Ask the custmer service prvider t qute yur OUTPATEINT, OUT-OF-NETWORK physical therapy benefits. These are frequently termed rehabilitatin benefits and can include ccupatinal therapy, speech therapy, and smetimes massage therapy and chirpractic care. ***Make sure the custmer service prvider understands yu are seeing an ut-f-netwrk prvider (r smetimes referred t as a nn-preferred prvider)*** Questins t ask the custmer service representative Name: Date/time: D I have Out-f-Netwrk Benefits fr Outpatient Physical Therapy? Yes N D I have a deductible? Yes N If yes, hw much is it? Hw much has already been met? D I have a per calendar year plan r a per benefit year plan? If per benefit year, what are my dates f cverage? What percentage f cverage is my respnsibility fr seeing an OON prvider? Des my plicy require a written referral r prescriptin? Yes N If yes, a written prescriptin frm ANY prescribing prvider? (eg: physician, nurse practitiner, pdiatrist, chirpractr) Yes N If n, des it have t cme frm a PCP (primary care prvider)? Yes N What is the name f the PCP n file? Artemis Physical Therapy, PLLC P a g e 1 2

10 Is pre-authrizatin required fr physical therapy services? Yes N If yes, d I have ne n file? Yes N What is the expiratin date? Is there dllar amunt r visit limit per year? Yes N If yes: Dllar amunt? Visit limit D I require a special frm t submit a claim? Yes N If yes, hw can I btain it? What is the mailing address where I shuld send claims/ reimbursement frms? Can I submit my claim n-line? Yes N Hw? Navigating insurance can be difficult, we will d everything we can t help yu with this prcess. Belw is sme helpful infrmatin. Please understand, this wrksheet was created t assist yu in btaining reimbursement fr Physical Therapy services and is nt a guarantee f reimbursement t yu. A deductible must be satisfied befre the insurance cmpany will pay fr therapy treatment. Submit all bills t help reach the deductible amunt. If yu have an ffice visit c-pay the insurance cmpany will subtract that amunt frm the percentage they will pay. This will affect the amunt f reimbursement yu will receive. The reimbursement percentage will be based n yur insurance cmpany s established reasnable and custmary/fair price fr the service cdes rendered. This price will nt necessarily match the charges billed; sme may be less, sme may be mre. If yur plicy requires a prescriptin r referral frm a prvider yu must btain ne t send in with the claim. Each time yu receive an updated referral yu ll need t include it with the claim. If yur plicy requires pre-authrizatin and the insurance cmpany desn t have ne listed yet, yu ll need t call the referral crdinatr at yur prvider s ffice. Ask her t file a referral fr yur physical therapy treatment that is dated t cver yur first physical therapy visit. Be aware that referrals and pre-authrizatins have an expiratin date and sme set a visit limit. If yu are appraching the expiratin date r visit limit yu ll need the referral crdinatr t submit a request fr mre treatment. Artemis Physical Therapy, PLLC P a g e 2 2

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