PHYSICAL THERAPY APPLICATION FORM
Welcome to NAKOA Fitness and Physical Therapy. Please fill out and submit your application. Please make sure to provide an answer to each question, even if a question is not applicable (n/a). Once completed, our team will review it and contact you to schedule your first visit.
Who is the NAKOA Member who referred you? Or else, how did you hear about us?
(We would like to reward them through our Member Referral Program!)
Would you like to subscribe to our NAKOA Newsletter? It's filled with amazingness!
Your background.... Your interests.
Please tell us a little about yourself so we can better serve you.
General Health Information
Now that we know who you are, please tell us about how you feel.
Please list any surgeries you may have had. If you have not had any surgeries, please answer none.
Do you currently smoke cigarettes? (No judgement!)
Do you currently have hypertension? (high blood pressure, specifically above 140/90)
Yes, it's high
Yes, it's high, but I take beta blockers to keep it down
Nope, I got it under control
Are you using any medication per your MD's recommendation?
If yes, please list them here:
Have you had an injury in the last 6 months?
If yes, please explain:
Who is your Insurance Carrier?
What is your policy number?
What is your Provider's Service Number (1-800 number on the back of the card):
Is your Provider an: HMO or PPO
Whether you are recovering from surgery, have a nagging injury, chronic pain, or just need preventative care, our Physical Therapists can help you. We want to get to know you and understand the activities that you love. We offer a continuum of care that is personalized for you.
- To treat disease, injury and disability by evaluation, examination, testing and use of rehabilitative procedures, manipulations, massage, exercise and physical agents including, but not limited to, mechanical devices, heat, cold, electricity and ultrasound in the aid of diagnosis or treatment
- To obtain physician information needed in diagnosis and evaluation
- To prevent or minimize residual physical injury or disability
- To aid the patient in achieving maximum potential within his or her capabilities
- To accelerate convalescence and reduce the length of the functional recovery
All procedures will be thoroughly explained to you before they will be performed. There are certain inherent risks with Physical Therapy treatment because you will be asked to exert effort and perform activities with increasing degrees of difficulty. It is possible that this could cause an increase in your current level of pain or discomfort or an aggravation to your existing injury. There is also a possibility that you could experience a new injury. If any activity causes you to feel increased pain or discomfort, stop the activity and notify your therapist. This will help reduce the risk of injury or aggravation of your condition(s). The Physical Therapist will take care to ensure that you are protected from any hazardous situation. You will never be forced to perform any procedure that you do not wish to perform.
NOTICE OF PRIVACY PRACTICES – ACKNOWLEDGEMENT
NAKOA Fitness and Physical Therapy keep a record of the health care services we provide you. We will not disclose your record to others unless you direct us to do so or unless a legal request authorizes or compels us to do so. We will provide copies of your records to your insurance company and referring physician as necessary to receive payment for our services. If you would like a copy of these records we would be happy to comply.
Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information. This policy can be viewed upon request.
Based on the above information I agree to cooperate fully and to participate in all Physical Therapy procedures and to comply with the plan of care as it is established.
MEDICAL ASSIGNMENT OF BENEFITS & FINANCIAL POLICY
We at NAKOA Fitness and Physical Therapy are pleased to be a part of your rehabilitation experience and thank you for choosing us. We find that communication with our patients regarding our financial policy assists in providing the best service to you. We will gladly call your insurance company to identify what your benefit coverage is, however, please understand that insurance companies will not guarantee medical benefits prior to care. We can only use this information as an estimated guideline. Actual determination is made 4 to 8 weeks later, after we receive the written notification and/or payments on your claim. We strongly encourage you to contact your insurance company directly in order to understand your plan’s coverage and limitations.
In the event that I, the patient, require more visits than my initially approved amount, NAKOA will request more visits from my insurance company as long as visits are medically necessary. I understand that visits that are preapproved will not necessarily be reimbursed and that I am responsible for any remaining amount due. Your insurance company may also require a current therapy prescription (prescriptions expire 30 days from the date they are written), a “Letter of Medical Necessity” written by your physician and/or preauthorization directly from your physician for therapy services. This is your responsibility to obtain, and noncompliance with this may result in services not being reimbursed by your insurance company.
All deductibles, copays, and cash pay estimated amounts are due at the time of service. Once we received all payments or notifications from your insurance company, we will notify you immediately if we find that the benefits verified are inconsistent with payment received. Payment for any outstanding balance will be due upon immediate receipt of patient responsibility statement. If we do not receive the payment, we may be forced to pursue legal collection proceedings. Please do not hesitate to ask us any questions or request a copy of your account balance.
Late Cancellation Policy: If you need to cancel your appointment, please do so more than 24 hours prior to the appointment time. If you cancel within 24 hours of the appointment time you will be charged a late cancellation fee of $45 dollars per visit.
By signing this form, I the patient (or legal guardian of the patient), have read, understood and agree that I am 100% responsible for all fees incurred at NAKOA Fitness and Physical Therapy that are not covered by my insurance company. I agree to authorize NAKOA Fitness and Physical Therapy to release my medical information to insurance companies, physicians, attorneys and to all other pertinent parties that may be involved in my claim or care. I also agree to assign all payment of benefits to NAKOA Fitness and Physical Therapy.
By signing below you confirm that you have read, and understand the financial policy and are aware of your financial responsibility according to the “explanation of insurance benefits” form.
Direct Physical Therapy
Treatment Services Disclosure
You are receiving direct physical therapy treatment services from an individual who is a physical therapist licensed by the Physical Therapy Board of California. Your physical therapist is a professional employee in this physical therapy practice, which will bill your insurance company and/or the patient for professional physical therapy services recommended and administered by the PT in the best interest of your personal health.
Under California law, you may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits, whichever occurs first, after which time a physical therapist may continue providing you with physical therapy treatment services only after receiving, from a person holding a physician and surgeon’s certificate issued by the Medical Board of California or by the Osteopathic Medical Board of California, or from a person holding a certificate to practice podiatric medicine from the California Board of Podiatric Medicine and acting within his or her scope of practice, a dated signature on the physical therapist’s plan of care indicating approval of the physical therapist’s plan of care and that an in-person patient examination and evaluation was conducted by the physician and surgeon or podiatrist.
With your written authorization, your physical therapist shall notify your physician and surgeon, if any, that he/she is treating you.