Pelvic Floor Intake Form

Patients

Patient History

Location:

When did your problem first begin?

Was the first episode of the problem related to a specific incident?

Since that time, is it:

Activities or events that may exacerbate your symptoms (check all that apply):

Fever/chills:
Malaise (unexplained tiredness):
Unexplained weight change:
Unexplained muscle weakness:
Dizziness/fainting
Night pain/sweats:
Change in bowel/bladder function:
Numbness/tingling:

General health::

One disability/leave?
Activity Restrictions?
Mental health: current level of stress:
Activity/Exercise::

Surgery for your back/spine:
Surgery for your female organs:
Surgery for your brain:
Surgery for your bladder:
Surgery for your bones/joints:
Surgery for your abdominal organs:

Childbirth vaginal deliveries:
Episiotomy:
C-section:

Difficult childbirth:
Prolapse:
Vaginal dryness:
Painful periods:
Menopause:
Painful vaginal penetration:
When did you begin Menopause?
Pelvic pain

ASSIGNMENT / INSTRUCTION FOR DIRECT PAYMENT TO HEALTH PROVIDER

I hereby instruct the insurance company/companies to pay by check made out to and mailed directly to POST Physical Therapy for professional or medical expenses allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered.

THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY.

This payment will not exceed my indebtedness to the above-mentioned assignee By signing below I have agreed to pay, in a current manner, any balance of said professional fees for non-covered services and/or fees, over and above the insurance payment or as required by my insurance policy. I understand that POST Physical Therapy complies with HIPAA and will protect my Protected Health Information (PHI) and will use it as allowable by law in the treatment, billing, and collection pertaining to my care until my case is closed and full payment is received. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or an attorney for the purpose of securing payment under this policy of insurance or to any Medical Provider associated with my case to effectively treat me. The authorization is in effect until 90 days from the date the last bill is collected.

HIPAA REGULATIONS

A photocopy of this Assignment shall be considered effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney for the purpose of securing payment under this policy of insurance under the HIPAA guidelines.

CONSENT TO TREATMENT AND DISCLOSURE OF PATIENT INFORMATION

I hereby authorize the professional staff at POST Physical Therapy to examine and treat me with physical therapy for the injury I have been referred here for or referred me to. I also authorize my protected health information to be disclosed to my insurance company (s), my doctor and /or other healthcare providers as well as my attorney.

PATIENT'S FINANCIAL RESPONSIBILITY

By signing below I authorize benefit payments directly to POST Physical Therapy that would otherwise be payable to me. I authorize POST Physical Therapy to securely store my credit card information, and only charge it should I have a co-payment, cancellation fee, deductible, coinsurance, or any leftover balance from a processed claim.

I understand that it is my sole responsibility to notify you in a timely manner of any change to the information I have provided. If I do not cancel or reschedule an appointment without giving at least 24 hours notice I may be charged a fee. If a check I provide bounces I understand there is a $50 fee. POST strongly suggests that I the patient contact my insurance company to verify benefit information. However, POST assumes no liability for any misunderstanding or errors made by my insurance carrier in regards to the information received and what my ultimate responsibility is for visits.

If no or incorrect insurance information is provided by the patient, visits will be processed at the self-pay rate. POST expects payment at the time of service. A prescription for Physical Therapy from a physician is required.

REMINDER PHONE CALLS ARE A COURTESY AND SHOULD NOT BE RELIED UPON FOR KEEPING TRACK OF YOUR APPOINTMENTS.

Patient Bill of Rights

All patients should be guaranteed the following freedoms:

To seek consultation with the physician(s) of their choice;
To contract with their physician(s) on mutually agreeable terms;
To be treated confidentially, with access to their records limited to those involved in their care or designated by the patient;
To use their own resources to purchase the care of their choice;
To refuse medical treatment even if it is recommended by their physician(s);
To be informed about their medical condition, the risks and benefits of treatment and appropriate alternatives;
To refuse third-party interference in their medical care, and to be confident that their actions in seeking or declining medical care will not result in third-party-imposed penalties for patients or physicians;

To receive full disclosure of their insurance plan in plain language, including:

CONTRACTS: A copy of the contract between the physician and health care plan, and between the patient or employer and the plan;
INCENTIVES: Whether participating physicians are offered financial incentives to reduce treatment or ration care;
COST: The full cost of the plan, including copayments, coinsurance, and deductibles;
COVERAGE: Benefits covered and excluded, including availability and location of 24-hour emergency care;
QUALIFICATIONS: A roster and qualifications of participating physicians;
APPROVAL PROCEDURES: Authorization procedures for services, whether doctors need approval of a committee or any other individual, and who decides what is medically necessary;
REFERRALS: Procedures for consulting a specialist, and who must authorize the referral;
APPEALS: Grievance procedures for claim or treatment denials;
GAG RULE: Whether physicians are subject to a gag rule, preventing criticism of the plan.