Full Legal Name:
Address:
City/State/Zip: , ,
Email: D.O.B.:
Mobile Phone#: *Alternate Phone:
*Emergency Contact Name: *Phone:
Gender:
Current Profession:
*How Can We Help?
*Have you had surgery recently? Yes No If yes, please advise:
*If you need Injury Management, do you have a physician's referral? Yes No N/A
If yes, provide details:
*If you need Injury Management, do you wish to go under Insurance for the first month? Yes No N/A
*Insurance Company Name:
*Provider or Customer Service Phone #:
*Policy #:
*Group #:
*Is this a Worker's Compensation claim? Yes No
*Is this a Automobile claim? Yes No
*What Are Your Goals?
Do you have any of the following conditions?
*Please explain any checked items above or advise if there are any other medical conditions your therapist should know about? (if none, please type in NONE)
What medications and vitamins are you currently taking?
*Are you pregnant?
Yes No
If yes, how many weeks?
*Have you seen a physician?
Yes No
*Do you have a physician prescription?
Yes No
What is your physician's name?
*Have you had any diagnostic testing?
Yes No
*Are you undergoing any other treatments?
Yes No
*What is your average pain level?
1 2 3 4 5 6 7 8 9 10
(no pain) (moderate) (extreme pain)
Please indicate the areas you want us to focus on by using the numbered diagram below:
Primary: Secondary: Tiertiary:
*Duration of Injury:
This is a recent injury (within the past month)
Sub-acute (1-4 months)
Chronic (More than 6 months)
*Primary Concern:
Loss of performance
Pain only
Loss of Function only
Loss of Function and Pain
Other:
*Does your knee give out on you?
Yes
No
If yes, please specify during which activities:
*Current Functional Mobility Level
Significant Limitations (more than 75% limited)
Moderate (50% to 75% limited)
Mild-moderate (25% to 50%)
Minimal Limitation (5% to 25%)
No Functional Limitations
*Current Functional Independence Level
Significant Limitations (more than 75% limited)
Moderate (50% to 75% limited)
Mild-moderate (25% to 50%)
Minimal Limitation (5% to 25%) – “I can do what I have to do only”
No Functional Limitations - – “I doing all I wish to do”
*Discharge Goal
I want to return to daily activities without pain
I want to condition myself to do what I have to do with proper mechanics
I want to return to my previous fitness and recreational/sport activities without pain
I want to improve the mechanics and performance with my previous fitness and recreational/sport activities
Other:
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Center Policies
Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Uses and Disclosures: Treatment: Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members. Payment: Your health information may be used to seek payment from your health plan from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated. Health care operations: Your health information may be used as necessary to support the day-to-day activities and management of Genesis Physical Therapy. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality. Law enforcement: Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting. Public health reporting: Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department. Other uses and disclosures require your authorization: Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorizations will not affect or undo any use or disclosure of information that occurred before you notified us of you decision to revoke your authorization. Additional Uses of Information Appointment reminders: Your health information may be used by our staff to send you appointment reminders. Information about treatments: Your health information may be used to send you information that you may find interesting on the treatment and management of you medical conditions. We may also send you information describing other health-related product and services that we believe may interest you. Individual Rights You have certain rights under the federal privacy standards. These include the right to: § Request restrictions on the use and disclosure of your protected health information § Receive confidential communications concerning your medical condition and treatment § Inspect and copy your protected health information § Amend or submit corrections to your protected health information § Receive an accounting of how and to whom your protected health information has been disclosed § Receive a printed copy of this notice Genesis Physical Therapy Duties We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice. Right to Revise Privacy Practices As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain. Complaints: If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to our contact person listed below: If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint. Contact Person The name and address of the person you can contact for further information concerning our privacy practices is: Todd Ball, P.T., Genesis Physical Therapy, Inc., 899 Logan Street, Suite 115, Denver, CO 80203. Tel: 303-393-1600, Fax: 303-393-1777
Consent for Treatment Consent for Physical Therapy:
Knowing that I am suffering from a condition requiring diagnostic or medical treatment, I hereby consent to care by Genesis Physical Therapy as they may deem necessary by their judgment, under the prescription of a licensed physician. I do hereby voluntarily consent to the rendering of care for a condition requiring physical therapy services. I understand and expect that the care I receive by Genesis Physical Therapy will meet customary standards, I do understand that medicine is not an exact science and acknowledge that diagnosis and treatment may involve risks of injury. I acknowledge that no guarantees have been made to me as a result of examinations of treatment. I hereby authorize Genesis Physical Therapy to retain any records for use, for research and for teaching purposes. If I refuse treatment that is suggested for me, I will not hold Genesis Physical Therapy or any individual responsible for any consequences resulting from my decision.
Cancellation Policies:
I am aware that if I do not cancel my physical therapy or wellness appointment within 24 business hours Monday thru Friday, I will be responsible for paying a $70 late charge for evaluations and $50.00 for follow up appointments or a deduction from my private package or class package. I am aware that insurance does not cover any late cancellations or no-shows and it must be paid out-of-pocket. The late fee will be automatically charged to the credit card on file that I provided to Genesis Physical Therapy.
Acknowledgement of Insurance Benefits:
I understand that it is my responsibility to know and understand my insurance benefits. Genesis assumes no liability for any errors made by your insurance carrier(s). It is your responsibility to clarify any discrepancies in eligibility, benefits and/or authorization and inform our clinic immediately. I understand and agree to pay any balance remaining after your insurance carrier(s) has paid its portion of the charges. If you are a self-pay client you will be responsible for payment at the time of each visit or prepayment if package is purchased. I have reviewed and understand, whether reviewing as a patient or otherwise, and am hereby individually obligated to pay for services rendered to the patient in accordance with the regular rates and terms of the company, which are not reimbursed by third parties. I further agree to bear legal fees and collection expenses, which may be incurred by the company, in collection of payment on the amount, if that amount becomes delinquent. I hereby authorize treatment by Genesis Physical Therapy and assign to Genesis Physical Therapy any and all benefits arising out of any type of insurance, which insures the my bill. I understand that the temporary acceptance of verified insurance coverage in lieu of payment does not release the patient form ultimate payment responsibilities. I hereby authorize Genesis Physical Therapy to release any or all information to third parties, including but not limited to employers and insurance companies, who may be liable to the patient or Genesis Physical Therapy for payment of charges to the patient. Genesis Physical Therapy reserves the right to modify the privacy practices outlined in the notice. I acknowledge having reviewed the Notice of Privacy Practices for Genesis Physical Therapy.
Studio Liability Release
In checking the box below I agree that Genesis PT and Fitness is in no way responsible for the safekeeping of my personal belongings while I attend class. I understand that classes may be physically strenuous and I voluntarily participate in them with full knowledge that there is risk of personal injury, property loss or death. I agree that neither I, my heirs, assigns or legal representatives will sue or make any other claims of any kind whatsoever against or its members for any personal injury, property damage/loss, or wrongful death, whether caused by negligence or otherwise.
Studio Liability Release Agreement
I agree
I have read, understand and agree to the Notice of Privacy Practices: I have read, understand and agree to the Consent for Treatment: I have read, understand and agree to the Cancellation Policies: I have read, understand and agree to the Acknowledgment of Insurance Benefits.