Intake Forms DOWNLOAD FORM HERE OR FILL HERE Step 1 of 4 25% Full Name(Required) Preferred Name(Required) Parent/Guardian (if minor)(Required) Relationship(Required) Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone(Required)Cell Phone(Required)Occupation(Required) Employer(Required) Email Address(Required) What is primary choice of communication(Required) Phone call Email Text Marital Status(Required) Employment Status(Required) Birth Date Gender(Required) Male Female Social Security Number (for billing your insurance)(Required) Emergency Contact Phone Number(Required)Name of physician who referred you to us(Required) Are you seeing us for a work injury or auto accident injury(Required) Yes No If yes, we will ask you for specifics after you return this form. Medicare patients only:Are you currently receiving any services from a home health agency (nursing, aide, therapy, speech, any in-home assistance): Yes No Are you covered under black lung disease, end stage renal disease, or are you covered under group insurance: Yes No Your PRIMARY insurance company Relationship to policy holder Self Spouse Dependent What is their date of birth:(Required) Your SECONDARY insurance company Relationship to policy holder Self Spouse Dependent What is their date of birth:(Required) Please describe what we are seeing you for(Required) Consent to Treat The patient has the right to informed participation in decisions involving his/her health care. This shall be based on clear, concise explanation of his/her condition and of all proposed treatment procedures. All possible risks and/or side effects, as well as the probability of success with such procedures shall be disclosed to the patient by his/her attending physical therapist. The patient shall not be subjected to any procedure without his/her voluntary, competent and understanding consent or consent of his/her legally authorized representative. Where medically significant alternatives for care or treatment exist, the patient shall be so informed. After reading the above, I hereby consent to receive physical therapy treatment at Bodyworx Physical Therapy, PLLC, commencing today and terminating when determined by myself, my physician, or my physical therapist. Patient Initials(Required) Authorization to Release/Receive InformationI give my consent to Bodyworx Physical Therapy, PLLC to disclose health information to my insurance carrier for the purpose of billing, to my physician or other healthcare professionals involved in my care, or receive health information from other healthcare professionals as it relates to my treatment, as permitted/required by law. I understand that confidentiality of my health information is protected under state and federal law, and that this release gives consent to Bodyworx Physical Therapy, PLLC only, and not to any party to whom such information is released. (Please refer to the Privacy Notice for a more complete description of such uses and disclosures. You have the right to review the notice prior to signing this consent.)Patient Initials(Required) Patient Payment Policy The fee schedule of Bodyworx Physical Therapy, PLLC is based on usual and customary fees for the type of services provided. Generally, your insurance policy will cover some portion, if not all, of the payment for services provided. There is, however, no guarantee of payment. The balance amount that your insurance carrier does not cover will be your responsibility. You are also responsible for any deductible and co-pay. **PLEASE NOTE, IF YOU HAVE A COPAY WITH YOUR PRIMARY INSURANCE, AND YOU HAVE A SECONDARY INSURANCE, WE WILL AS A COURTESY TO YOU SUBMIT THIS TO YOUR SECONDARY INSURANCE A MAXIMUM OF TWO TIMES. IF NO PAYMENT IS RECEIVED OR YOUR SECONDARY INSURANCE DOES NOT RESPOND, YOU WILL BE BILLED AND EXPECTED TO PAY THE BALANCE, AT WHICH TIME YOU WILL BE GIVEN A "PAID" RECEIPT THAT YOU WILL THEN BE ABLE TO SUBMIT TO YOUR SECONDARY INSURANCE FOR REIMBURSEMENT. We request that any insurance payments that are sent directly to you be presented promptly to Bodyworx Physical Therapy, PLLC along with the explanation of benefits and/or any other information you received with the payment. You are directly responsible for payment of medical supplies. Monthly statements will be sent to you if you have an outstanding patient balance. Payment for your portion of services, as outlined in the statement under the "Due From Patient" column is requested to be paid within fifteen (15) days of receipt of the statement. I attest that my insurance coverage and personal financial responsibilities regarding physical therapy treatments have been fully explained to me. Patient Initials(Required) Medicare Patients Only I request that payment of authorized Medicare benefits be made to me or on my behalf to the practitioner named above. I authorize any holder of medical information about me to release to the Health Care Financing administration and its agents any information needed to determine benefits or the benefits payable for related services. I have read this information and understand its content. Patient Initials(Required) Receipt of HIPAA Notice of Privacy Practices Signature below is acknowledgement that you have received the notice of our privacy practices:Signature(Required)Date(Required) Patient Name(Required) Date(Required) Date of Injury/Onset(Required) Date of next physician's visit(Required) Briefly describe how you were injured or onset of condition(Required)Date of surgery for this condition (if applicable) Diabetes(Required) Yes No Heat intolerance(Required) Yes No Chest Pain/Angina(Required) Yes No Cold intolerance(Required) Yes No High Blood Pressure(Required) Yes No Allergies(Required) Yes No Heart Attack(Required) Yes No Hernia(Required) Yes No Heart Disease(Required) Yes No Seizures(Required) Yes No Pacemaker(Required) Yes No Metal Implants(Required) Yes No Headaches(Required) Yes No Dizziness/Fainting(Required) Yes No Kidney problems(Required) Yes No Recent Fractures(Required) Yes No Are you pregnant?(Required) Yes No Surgeries(Required) Yes No Cancer(Required) Yes No Nausea/Vomiting(Required) Yes No Osteoporosis(Required) Yes No Ringing in Ears(Required) Yes No Bowel/Bladder Condition(Required) Yes No Arthritis(Required) Yes No Asthma/COPD(Required) Yes No Hypoglycemia(Required) Yes No Stroke/TIA(Required) Yes No Other(Required) Yes No Other CALL FOR AN APPOINTMENT: 405-253-5076 Fax: 405-253-5683 Email:info@bodyworxpt.com Follow Us
