1) Have you had any surgeries? Type of surgery and date

*** Please present your insurance card and photo identification so that we may make a copy ***

I understand that my treatment may be located in an open area or an area separated by curtains. I understand that, as desired, it is my responsibility to ask that the curtains be closed for privacy or that I be placed in a private room (if available) at my appointment time. I hereby consent to physical therapy treatment at South Fork Physical Therapy and Rehab, PLLC. I am here, and being treated, by my own free will and understand that I may stop treatment at any time if I feel the need to do so. I understand that it is my right to ask questions and receive appropriate responses regarding my treatment and / or outcomes.

THIS DOES NOT APPLY TO PATIENTS COVERED BY WORKER’S COMPENSATION

In consideration of services rendered and to be rendered by SFPT, I hereby guarantee payment of all charges incurred for the account of the above named patient from date of admission through discharge. I understand and agree that payment for such services shall be due at the time of discharge. I authorize and direct any person, firm, or corporation, including but not limited to insurance companies or attorneys representing the patient or any other party for such services, to assign proceeds of any payment for services rendered to said patient directly to SFPT. I understand that by SFPT’s acceptance of assignment of said benefits, SFPT does not relinquish its right to collect any balance not paid by any third party. I hereby authorize payment directly to SFPT of all insurance benefits otherwise payable to me but not to exceed the total charges for this period of treatment. I understand that I am financially responsible to SFPT for all charges not covered by this authorization. I further agree that if such indebtedness is placed in the hands of a collector or attorney for collection, I will pay reasonable collection fees and attorney fees, interests, court costs and other collection expenses. In order for SFPT or their designated external collection agency to service my account, and where not prohibited by applicable law, I agree that SFPT and the designated external collection agency are authorized to (i) contact me by telephone at the telephone number(s) I am providing, including wireless telephone numbers, which could result in charges to me, (ii) contact me by sending text messages (message and data rates may apply) or emails, using any email address I provide and (iii) methods of contact may include using pre-recorded/artificial voice message and/or use of an automatic dialing device, as applicable. Private Pay patients are required to render payment at time of Check-In. No services can be rendered until any/all patient balances are paid in full.

Acknowledgement of Receipt of Privacy Practices for Physical Therapy

You may refuse to sign this acknowledgement but, in refusing we will not be allowed to process your insurance claims.

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this facility. A copy of this signed, dated Acknowledgement shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST DOCUMENTS BE SENT TO OTHER ATTENDING DOCTOR / TREATMENT
FACILITY IN THE FUTURE

I AUTHORIZE INFORMATION ABOUT MY HEALTHCARE BE CONVEYED VIA:

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this facility may recommend products or services to promote your improved health. This facility may or may not receive third party remuneration from these affiliated companies We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.

You may supply your own list or have your pharmacy fax to our office. If you need room for additional medications, please advise our office personnel.

Are you 60 years of age or older?