impactrehab

Impact Rehabilitation Center

Patient Registration Form
Date

MonthDayYear
Date
Patient Name: (Last, First, Middle Initial)
Gender
Date of Birth

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState

ZIP Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Yes
Email
example@example.com
Yes
Social Security # ( Required for VA patients)
Marital Status
YesNo
Employment Status
Occupation
Employer
Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
Employer Address

Address

Street Address Line 2

CityState

ZIP Code
Emergency Contact Name
Emergency Contact Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient
Emergency Contact Address

Address

Street Address Line 2

CityState

ZIP Code
Financially Responsible Party Other Than Patient
Name: (Last, First, Middle Initial)
Relationship to Patient
Address

Address

Street Address Line 2

CityState

ZIP Code
Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Social Security # (Required for VA patients)
Gender
Date of Birth

MonthDayYear
Date
Injury Information
YesNo
Date of Surgery

MonthDayYear
Date
Surgical Procedure
YesNo
YesNo
Date of Accident

MonthDayYear
Date
Describe Accident/Injury/Illness

0/80
YesNo
Date of Injury

MonthDayYear
Date
Full-timePart-timeNo
Name of employer at time of accident
City
State
ZIP Code
YesNo
Name of Attorney
Attorney Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Information
Primary Insurance
Claims Mailing Address

Claims Mailing Address

Street Address Line 2

CityState

ZIP Code
Subscriber Name
Date of Birth

MonthDayYear
Date
MaleFemale
Relationship to Patient
ID Card # (including alpha prefix)
Group #
Secondary/Supplemental Insurance
Claims Mailing Address

Claims Mailing Address

Street Address Line 2

CityState

ZIP Code
Subscriber Name
Date of Birth

MonthDayYear
Date
MaleFemale
Relationship to Patient
ID Card # (including alpha prefix)
Group #
The above description is a quote of your insurance(s) benefits. We assume no liability for any errors made by your insurance carrier(s) in this quotation. It is your responsibility to clarify any discrepancies in eligibility, benefits and/or authorization and inform our clinic immediately. We have reviewed these benefits with you. You understand and agree to pay any balance remaining after your insurance carrier(s) has paid its portion of the charges.
Patient Initials
Date

MonthDayYear
Date
ASSIGNMENT OF INSURANCE BENEFITS
1. The undersigned agrees, whether signing as agent or patient, and it 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. The undersigned further agrees 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.

2. The undersigned hereby authorizes treatment by Impact Rehabilitation Center and assigns to Impact Rehabilitation Center any and all benefits arising out of any type of insurance, which insures the patient's bill. The undersigned understands that the temporary acceptance of verified insurance coverage in lieu of payment does not release the patient from ultimate payment responsibilities.

3. The undersigned hereby authorizes Impact Rehabilitation Center 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 Impact Rehabilitation Center for payment of charges to the patient.
Patient Signature

Clear
Date

MonthDayYear
Date
Medical History
Name
Date of Birth

MonthDayYear
Date
Reason for Physical Therapy:

0/50
Date of Onset / Injury

MonthDayYear
Date
YesNo
X-rayMRICT ScanEMG
Past Surgical Procedures / Injuries & Date (orthopedic & neurologic, &/or related to this condition):

0/150
Medical DoctorChiropractorMassage TherapistPhysical TherapistHome Health CarePsychologistAcupuncture
If you have seen any of the above during the past three months, please describe for what reason:

0/150
YesNo
List any medications you are allergic to
Any other allergies we should know of?
Please list all medications currently taking:

0/80
In case of a medical emergency:
if Yes for either, please provide a copy for your chart
YesNo
YesNo
High Blood PressureHeart Arrhythmia / MurmurAnemiaStrokeEmphysemaHeart DiseasePacemakerSeizuresBrain InjuryTuberculosisHeart AttackDiabetesCancerDementiaAsthmaKidney DisorderSpinal Cord InjuryParkinson’s DiseaseScoliosisChronic Fatigue SyndromeFatigue
DepressionSensory Integration DisorderDizzinessShortness of BreathHeadachesPelvic Floor PainHepatitis / HIVMultiple SclerosisCirculation ProblemsOsteoporosis / OsteopeniaADHDFibromyalgiaWeaknessNumbness & TinglingChronic PainInjured in Motor Vehicle AccidentHerniaRheumatoid ArthritisOsteoarthritisAnxietyAutismUnexplained Weight LossBowel / Bladder Incontinence
Other Neurologic Disorder
Other Autoimmune Disorder
Other Psychiatric Disorder
Please describe any other medical conditions / injuries/ information about your health you would like us toknow:

0/100
Signature

Clear
Date

MonthDayYear
Date
Patient Name
Consent to Treat
Patient's Name
I hereby authorize IMPACT Rehabilitation Center (IRC) and any of its representatives, to treat me and provide medical services related to my treatment. I understand that there are risks related to the treatment of my condition, and willfully accept any and all risks associated with the treatment and care provided for me. I also undertake any exercises or training endeavors, which might be requested of me by my therapy provider, with the full knowledge that there does exist potential for physical injury with adverse physical and/or psychological reaction to them. In participant in the treatment provided at IRC, I do so with the understanding that although IRC will make reasonable efforts to obtain and consider information that might preclude my participation, it is my added responsibility to notify IRC of any condition which should preclude me from the participation in the treatment and services provided.
Patients Signature

Clear
Date

MonthDayYear
Date
Consent for Minors: As legal guardian, I hereby authorize IRC and any of its representatives to treat and provide medical services related to the treatment of the minor listed above. I agree with the above statement in relation to the minor.
Legal Guardian's Signature

Clear
Date

MonthDayYear
Date
Financial Policy
The following information is provided in addition to the assignment of insurance benefits to avoid any misunderstanding or disagreement concerning payment for professional services rendered.

A medical insurance policy is a contract between you and your insurance company. Coverage depends upon your insurance company and the specific plan you have chosen. It is your responsibility to know and understand your insurance benefits and cost share.
Initials
IMPACT Rehabilitation Center will submit claims to your insurance company on your behalf, however it is your responsibility to remit payment for all charges not covered by your claim and insure your carrier remits payment.
Initials
All patient cost shares including co-payments, co-insurances, and deductibles are due at the time of treatment
Initials
I acknowledge that IMPACT Rehabilitation Center will apply a 3% surcharge for all payments made by credit / debit card. There is no surcharge for payments made by check or cash.
Initials
I authorize IMPACT Rehabilitation Center to charge my credit card on file for my co-pay / co-insurance + 3% surcharge for each date of service.
Initials
For patients with co-insurance and deductible, we will be asking you to pay an estimate of what you will owe for each treatment session. Once your insurance carrier adjudicates the claim, we may have to bill you for the remaining balance. Please note that insurance companies often adjudicate claims for some dates of service a few months after the treatment session concludes.
Initials
Cancellation Policy
As a courtesy to our staff and other patients, IMPACT Rehabilitation Center requires advance notice for cancellation of appointments. If you need to cancel, please call or text our office the business day prior to your appointment, so as not to incur a cancellation charge.
Initials
If you do not call or text to cancel your appointment AT LEAST 2 hours prior to your appointment time, or do not show up for your appointment without notice, a $25 charge will be assessed prior to beginning your next appointment.
Initials
Thank you for your understanding and courtesy to our staff and other patients.
I, name have read, understand, and agree with the above information.
Signature

Clear
Date

MonthDayYear
Date
I have read the material provided me regarding the HIPAA OMNIBUS Privacy Act, and understand my rights and choices.

I also have read and understand the material in regard to the clinic's responsibilities under the HIPAA OMNIBUS Privacy Act.

I have also been informed that I can obtain further information

regarding the HIPAA OMNIBUS Privacy Act at the following website:
HIPAA Home | HHS.gov

I therefore freely affix my signature below with full understanding of all of the above.
Patient Signature

Clear
Date

MonthDayYear
Date
Patient Name
Signature of Patient Representative/Guardian

Clear
Date

MonthDayYear
Date
Printed Name of Patient Representative/Guardian
Relationship of Patient Representative/Guardian
Patient Name being Represented
Should be Empty:

Impact Rehabilitation Center

Financially Responsible Party Other Than Patient

Injury Information

Insurance Information

ASSIGNMENT OF INSURANCE BENEFITS

Medical History

In case of a medical emergency:

Consent to Treat

Financial Policy

Cancellation Policy