inspirept_Patient_Information

Patient Name

Email Address

example@example.com

Billing Address:

City State ZIP

PCP/Referring Physician

DOB

Date

Sex

MaleFemale

Gender pronouns

Marital status

MarriedSingleWidowedDivorced

Mailing Address (if different):

City State ZIP

Home phone

Cell phone

Emergency contact

Relation to emergency contact

Phone number of contact

ID number

WC or Auto Accident claim number

Insurance name

I voluntarily consent to physical therapy treatment and services deemed necessary by my physical therapist and/or physician. I am aware that the practice of Physical Therapy is not an exact science and I acknowledge that no guarantees have been made to me as to the results of these services at Inspire Physical Therapy. It is the clinic's sincere intent to educate me on every process, from billing to treatment and eventually discharge from services. Therefore, if techniques are being used that I do not understand it is my responsibility to ask the therapist what his/her objectives are and how he/she is trying to achieve them. This consent shall be ongoing for a period not to exceed one year.

Signature Patient/Parent/Guardian

Date

I have received the Notice of Privacy Policies from Inspire Physical Therapy.

Signed Patient/Parent/Guardian

Date

Name

If acknowledgement is refused list reasons for refusal and efforts to obtain acceptance.

Name

Todays date

Date

I am happiest when I participate in these activities:

I am here today because:

This began

What is it you want to do that you cant do now

I am taking medications for

Latex allergy?

YesNo

Previous surgery(s)/injuries

Please identify up to 3 important activities that you are unable to do or are having difficulty with as a result of your__________problem. (eg getting dressed, walking your dog, yard work, sports activities etc). Please list the most limited first.

1

2

3

Please indicate on the pictures the location of your issue(s) using the corresponding letters

Please indicate your level of discomfort at its WORST and BEST on the scale below

General Health. Do you have, or haveyou had, any of the following?

	Yes	No
Cancer
Diabetes
Pregnant (currently)
Metal implants
High blood pressure
Seizures
Concussion

Neck/Jaw/Head

	Yes	No
Do you experience facial pain?
Do you feel a click or pop when you open or close your mouth?
Do you experience weekly headaches?
Do you wake up with a dry mouth?
Do you feel pain in the front of your ear, or ear “fullness” or “ringing”?
Do you feel tension at the base of your skull when you turn your head in the upright position?
Do you use a dental splint?
Are you missing teeth?

Breathing

	Yes	No
Do you snore?
Do you have diﬃculty breathing with simple activity, ie going up steps?
Do you feel tired after a full night of sleep?
Do you have asthma?
Do you use an inhaler?
Do you have to sleep in an upright position?
Have you been diagnosed with sleep apnea?
Do you smoke?

How many hours do you sleep per night?

Feet

	Yes	No
Do you have flat feet?
Do you have pain on the bottom of your feet when you are standing?
Do you have a large bony bump near either of your big toes (bunion)?
Do you have orthotics,heel lifts, or any other foot inserts in your shoes?
Does one of your feet turn out more than the Other?
Do you feel unstable with one or both of your ankles?

Vision

	Yes	No
Do you wear contacts?
Do you wear glasses?
Do you wear bifocals?
Do you occasionally bump into objects while walking?
Do you have diﬃculty driving at night?
Do you have blurry vision or double vision?
Do you feel dizzy?
Do you feel lateral leg & ankle strain, back tightness, or pain at the bottom of one or both feet?

Lumbo/pelvic/femoral

	Yes	No
Do you ever experience small amounts of urine leakage associated with a strong sensation of needing to go to the bathroom?
Do you experience frequent trips to the bathroom that disrupt your day or do you plan trips out based on where the bathrooms are?
Do you experience pain, discomfort or pressure in your pelvic area when sitting or standing for prolonged periods of time?
Do you frequently strain to have a bowel movement or to empty your bladder?
Do you experience the sensation of pressure in your lower abdomen or pelvic region?

Diet:

	Yes	No
Do you suffer from any of the following: Nausea or vomiting, diarrhea, constipation, bloated feeling, belching or passing gas, heartburn, intestinal/stomach pain?
Do you have frequent issues with any of the following: stuffy nose, sinus problems, hay fever, sneezing attacks, excessive mucus formation?
Do you suffer with inflammation?
Do you have good poor energy levels throughout the day?
Do you have concerns about your weight?
Would you be interested in seeing a Dietician?

Would you describe your diet as:

GoodAverageBad

Mental health:

	Yes	No
Would you like a referral to a mental health professional for help coping with emotions and stressors?
Would you like a referral to a peak performance coach for mental skills training if you are an athlete striving for a goal?

Thank you for choosing Inspire Physical Therapy for your physical therapy needs. This financial agreement describes both patient and insurance responsibility for services rendered. Please read this agreement, ask us any questions you may have, and sign in the space provided.

Payment Options - Credit Card on File

In an effort to speed up your check-in process in the office and allow you to pay for your visit if you do not have your credit card with you, we now have the ability to securely store your credit card(s) in our system. Your full credit card number will be encrypted and tokenized, and will never be viewable or accessible to any staff members. This information is stored in an offsite, secure vault that exceeds all HIPAA and PCI Data Security Standards. We will also never charge for any services that you do not authorize.

I authorize Inspire Physical Therapy to store my credit card information and bill the (encrypted and tokenized) credit card on file for services I receive at Inspire PT. I understand that Inspire Physical Therapy will only charge this credit card for amounts authorized by myself and that upon my request a receipt will be provided for all charges processed in our practice location. I will notify Inspire PT in writing if I no longer want my credit card information maintained. I understand that if I do not want my credit card billed for this purpose, I am still responsible for these fees and will be billed accordingly.

Signature

Printed Name

Date

Insurance

Your insurance coverage is a contract between you and the insurance company and we are not a party to that contract. We must emphasize that as medical care providers, our relationship is with you, not your insurance company. It is also your responsibility to know your insurance benefits including referrals, pre-certifications and required authorizations. As a courtesy we will submit your claims to your primary and secondary insurance companies; however, we do expect payment for all services within 60 days. It may become necessary for you to pay your account in full if your insurance fails to do so within 60 days. If we are given incorrect or incomplete insurance information, you will be billed and payment will be expected within 30 days of the date on the statement, unless the issue is resolved.

Patient Responsibility & Payment Payment of copays and deductibles will be due at the time of service. Our failure to collect these amounts may be a violation of our contract with your insurance company. You are ultimately responsible if your insurance denies a claim for any reason. If you do not have insurance, payment in full will be due at time of service. The amount of your bill is expected to be paid in full within 30 days of the date on the statement, unless payment arrangements have been made with us. Anything over 30 days is considered past due.

Attendance Policy

Inspire Physical Therapy strives to provide each patient with the highest quality care while accommodating patient schedules. We reserve time slots for each patient in order to minimize waiting time and assure continuity of care. Your consistent attendance of the planned treatment regimen is paramount to your full recovery.

Last minute cancellation and patient no-shows decrease our ability to accommodate the scheduling of other patients in need, so if you are unable to keep a scheduled appointment, we request 24 hours advance notice- failure to do this will result in a $50 charge after the 2nd same-day cancellation within 30 days. Inspire Physical therapy reserves the right to charge you a $50 No-Show Fee for any missed appointments. Your insurance will not be billed for that visit. If you are going to be late for an appointment, please let us know as soon as you can. We will do our best to accommodate you; however, there may be times we will need to reschedule.

I have received this financial policy, and understand that regardless of any insurance coverage I may have, I am responsible for payment of my account. I understand that delinquent accounts will be referred to a collection agency. If it becomes necessary to send my account to a collection service, I agree to reimburse Inspire Physical Therapy the fees of any collection agency, which may be based on a percentage at a maximum of 30% of the debt, and all costs, and expenses, including reasonable attorneys' fees, we incur in such collection efforts.

Patient Signature

Printed Name

Date

Parent/Guardian Signature

Parent/Guardian Printed Name

Date

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION PLEASE READ AND REVIEW IT CAREFULLY.

1. About Protected Health Information "PHI" In this notice, "we" or "us" refer to Inspire Physical Therapy, and our workforce of employees and volunteers. "You" or "your" refers to each ofour patients who are entitled a copy of this notice. We will use good faith regarding protecting your privacy, however, it is no guarantee from any and all potential risks.

We are required by federal and state law to protect the privacy of your health information. For example, federal health information privacy regulations require us to protect health information about you in a manner that we describe here. Certain types of health information may specifically identify you. Because we must protect this health information, we refer to it as "Protected Health Information" or "PHI". In this notice we will tell you about:

How we will use your PHI

When we may disclose your PHI to others

Your privacy rights and how to use them

Our privacy duties

Who to contact for more information or a complaint

2. Some ways we use or disclose your Protected Health Information We will use your PHI to treat you. We will use your PHI and disclose it in order for us to get paid for your care. We are allowed to dispense or disclose your PHI for certain activities that we call "health care operations". Health care operations involve the administration and quality assurance activities in our facility. We will give you examples of each of these to help explain them. However, this is NOT a complete list of all uses or disclosures.

Treatment:

We use and disclose your PHI in your course of treatment. For example, if you are in our clinic and one of our employees has a question about your condition, we may communicate with your treating physician regarding your diagnosis and plan of care SO that we can provide the optimal course of treatment for you. We may also disclose your PHI for other related types of treatment activities. It may be necessary for us to communicate with your referring physician regarding your evaluation and progress in therapy. This may include an introductory letter from our clinic informing the physician of your injury/injuries, as well as who your therapist is in case the physician needs to contact them. This may also include evaluations, progress notes, etc. This allows us to keep a line of communication with your physician about your progress and plan of care.

Marketing:

We may contact you to provide you appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Payment:

After we treat you, we will ask your insurer to pay us. We use a billing company to administer our billing for us. We provide our billing company your medical information SO that they can provide the required information to your insurance company. We, or our billing company, might input some information into our computers to send a claim to your insurance company. In this instance, we or our billing company, tell your insurer what type of health problem you had and what we did to treat you. Your insurer may ask us to give them your claim or subscriber number or your insurer may want to review your medical records to be sure your care was necessary.

Special Uses:

We may also use or disclose your PHI for the purposes that involve your relationship to us as a patient. We may use or disclose your PHI to:

Remind you that you have an appointment with us for treatment

To contact you regarding your patient account.

Your Authorization May be Required:

In many cases summarized here, we may use or disclose your PHI either with your consent or as required or permitted by law. In all other cases we must ask for, and you must agree to give, a written authorization that has specific instructions and/or limits on our disclosure of your PHI. If you later change your mind, you may revoke your authorization.

3. Certain Uses and Disclosures of your PHI that are Required or Permitted by Law.

Many laws and regulations apply to us that affect your PHI. These laws and regulations may either require us or permit us to use or disclose your PHI. From the federal health information privacy regulations, here is a list describing required or permitted uses and disclosures.

If you do not verbally object, we may share some of your PHI with a family member or friend who is involved in your care

We may use your PHI in an emergency when you are not able to express yourself.

When required by law: for example, when a subpoena is ordered by a court to turn over certain types of your PHI, we must do SO.

For public health activities such as reporting a communicable disease or reporting an adverse drug reaction to the Food and Drug Administration (FDA

To report abuse, neglect, or domestic violence, as required by law. To government regulators or its agents to determine whether we comply with all applicable rules and regulations. When properly requested by law enforcement, or for other legal requirements. If we believe that disclosing your PHI will avert a potential health hazard or threat to public safety. such as an imminent crime against another person. If you are in the armed forces, and it is deemed necessary by appropriate military personnel If your workers' compensation claims carrier requires various PHI information. 4. Certain Requirements We must Follow: Several state laws may apply to your PHI that set stricter standards than the protections required by federal health privacy regulations. 5. Your Privacy Rights and How to Exercise Them. You have specific rights under the federally required privacy program, these are summarized here. Your Right to Request Limited Use or Disclosure You have the right to request that we do not use or disclose your PHI in a particular way. However, we are NOT required to abide by your request. If we do agree with your request, we must abide by the agreement Your Right to Confidential Communication You have the right to receive confidential communication from us at the location you provide. We require that you make your request in writing, providing us with the other address and explain to us if the request will interfere with your care. Your Right to Revoke Your Consent or Authorization If you have granted us your consent or authorization to use or disclose your PHI, you may revoke the consent or authorization in writing. However, if we have relied on your consent or authorization we may use or disclose your PHI to that extent. Your Right to Inspect and Copy You have the right to inspect and copy your PHI. We may refuse to give you access to your PHI if we think it may cause harm, but we must explain why and provide you with someone to contact about our decision who will explain how and when to get a review of our refusal. Your Rights to Amend Your PHI If you disagree with what your PHI in our records say about you, you have the right to request in writing that we amend your PHI, when it is in a record that we have created or maintained for our purposes. We are not required to respond to your request if the records in question are not our records. You then have the right to submit a written statement as to why you disagree. We may then prepare a counterstatement, both of which will become a part of our record about you. Your right to Know Who Else Sees Your PHI You have the right to request an accounting of certain disclosures that we have made of your PHI over the past six years. We do not have to account for all disclosures including those pertaining to treatment, payment, and health care operations as described above. There is no charge for an annual accounting, but there may be a charge for additional accounting. You have the right to withdraw that request at any time. Your rights To Complain If you believe your privacy rights have been violated, you have the right to make a complaint to us, or to the Secretary of Health and Human Services. We will not retaliate against you if you make a complaint against us. To file a complaint, you must submit it in writing to the contact listed in section 7. below. You should provide us with a reasonable amount of detail to enable us to perform a proper investigation. 6. Some of Our Privacy Obligations and How We Perform Them. We are required to comply with the federal health information privacy regulations. These rules require us to protect your PHI. These rules require us to give you notice of our privacy practices. This document is our notice. If you did not get a paper copy of this notice, you may have one. We will abide by the privacy practices set forth in this notice. However, we reserve the right to change this notice or our privacy practices as permitted by law. If we change our notice of privacy practices, we will provide a revised notice when you next receive treatment from us.

7. Contact Information Inspire Physical Therapy Oliver Hall, PT, PRC 47 Commerce Street Colchester, VT-05446

8. Effective Date This notice takes effect March 1, 2017+

Patient Information

Primary insurance information:

Secondary insurance information:

Medically informed consent:

HIPAA Privacy Policies

Intake Form

Payment Policy and Financial Agreement

Health Information Privacy Notice