Motion New Patient Packet 2015

3280 Peachtree Road NE, Suite 160, Atlanta, GA, 30305 | All Appointments: (404) 382-8702 | www.motionstability.com | www.movementsportspt.com

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Today’s Date: _______

Patient Information Social Security # Title Last Name First Name MI

Street Address (Road or Street) Patient Data: (Nick Name)

Zip Code City State Date of Birth Sex (M, F)

Home Phone Cell Phone Email Address for Appointment Reminders (Will also be added to our e-newsletter list. Please let us know if you want to opt out.)

Referring Doctor: Full Name Address Phone Marital

M-Married W-Widowed S-Single D-Divorced X-Separated

Employment R-Retired F-Full P-Part N-None

Student P-Part F-Full N-None

Relationship to Insured SE-Self SP-

Spouse OT-Other CH-

Child Employer: Name Street Address (Road or Street)

Zip City State Business Phone Ext

Emergency Contact: Name Phone Number Relationship

INSURANCE INFORMATION Primary Insurance Company Name Mailing Address Insurance Telephone # Policy # Group #

Secondary Insurance Company Name Mailing Address

Secondary Telephone # Policy # Group #

COMPLETE IF INSURANCE IS IN SPOUSE’S/PARENT NAME

Social Security # Title Last Name First Name MI

Birthday Sex (M, F) Relationship to Insured:

ACCIDENT DETAILS- Please complete if visit is due to injury Employment related: Yes No

Accident Related: Auto Other No

Date of first symptom/accident:

Give Details of Accident:

Referred By: Physician Physical Therapist Family Friend / Colleague Other: ___________________________


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Case History

Date of Injury:_______________________

Primary complaint(s)?_____________________________________________________________________________________________

Surgery Performed? Yes No If Yes, Date/Type of Surgery:______________________________________________

Have you been hospitalized for this complaint? Yes No If Yes, date range:___________________________

Have you fallen in the past year? Yes No

Is your injury related to a fall? Yes No If Yes, date of fall:________________________

Symptoms

GoalsWhat are your goals / reasons for treatment in Physical Therapy?___________________________________________________________

________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Work

Auto Accident

Sports Injury

What aggravates your primary complaint(s)? __________________________________________________________________________

What eases or alleviates your primary complaint(s)?___________________________________________________________________

Are your symptoms?: Improving Unchanging Worsening

Have you had previous similar occurrences of these symptoms? If so, how often? ____________________________________________

_____________________________________________________________________________________________________________________

Which treatments have you had for this condition?

Medication

Injection

Physical Therapy

Massage

Trauma

Chronic

Chiropractic

Acupuncture

Other:_________________________

What are your symptoms related or due to?

Other:_________________________

Name: _______________________________________ Age:________________________ Today’s Date:________________________


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Pain ComplaintsPlease use the picture to indicate the affected areas:

Pain Scale

1 No Pain2 Mild Pain: you are aware of it, but it does not bother you3 Mild Pain: you become more aware of it, but only begins to bother you4 Mild Pain: you can tolerate it without medication5 Moderate Pain: requires medication to tolerate6 Moderate Pain: you begin to feel antisocial7 Severe Pain: you cannot participate in recreational activities8 Very Severe Pain: you cannot participate in activities of daily living9 Intensely Severe Pain: you cannot participate in activities of daily living10 Extremely Severe Pain: you cannot get out of bed11 Most Extreme Pain: it may make you contemplate suicide

Using the above scale, how do you rate your pain (0-10)?

At best? __________ Current?__________ At worst?__________

How would you describe your pain? - If more than one, please rank (1,2,3...) which best describes your pain.

Burning

Sharp

Dull/Achey

Throbbing

Shooting

Numbness/Tingling

Constant

Intermittent

Worse in morning

Worse in evening

Worse when sleeping

Other:_____________

ConstantIntermittent / Daily

OccasionalSporadic Other:_____________

Diagnostic Testing / Imaging

What is the frequency of your pain?

X-rayMRINerve conduction/EMG Bone ScanCardiac Stress Test

Doppler StudiesUrinalysis/UrodynamicBlood TestCT ScanUltrasound

Other:_____________

RESULTS:___________________________________________________________________


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Medical HistoryDescribe your general health? Excellent Good Fair PoorDo you smoke? Yes No If yes, how often?_________________

Please check any of the following that apply to you:

AllergiesAnemiaAnxietyArthritisAsthmaBladder conditionsBowel conditionsCancerCardiac ConditionsCardiac PacemakerChemical DependencyCholesterol ConditionsCirculation ProblemsCurrently PregnantDepressionDiabetes Type 1

Diabetes Type 2Dizzy SpellsDysmenorrheaEating DisordersEmphysema/BronchitisEndometriosisFibroidsFood SensitivitiesFracturesGallbladder ProblemsHepatitisHigh Blood PressureIncontinenceKidney ProblemsMenopauseMetal Implants

Motorized AccidentsMultiple SclerosisOsteoporosisParkinson’s DiseaseProstate ConditionsRecent FeverRheumatoid ArthritisSeizuresStraining with UrinationStrokesThyroid DiseaseUrgency with UrinationVulvodyniaVestibular ConditionsVision ProblemsRecent WeightLoss/Gain

Surgical HistoryBody Region:___________________ Surgery Type:__________________________ Date of Surgery:_________________

Body Region:___________________ Surgery Type:__________________________ Date of Surgery:_________________




Medications / SupplementsType:____________________Dosage:________________Started:______________Reason for Taking:______________________

Type:____________________Dosage:________________Started:______________Reason for Taking:______________________




I attest that the above information is truthful and accurate regarding my medical condition.

Patient Signature: _____________________________________________________ Date:_________________________

If you indicated ‘Yes’ on any of the above, or if you have any other medical conditions not listed above, please describe in

further detail, including any precautions:

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________


_________________________________________________________________________________________________________________Signature Date

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Informed Consent To Treatment

Dear Patient,

Physical Therapy involves the use of many different types of physical evaluation and treatment. The patient should

understand that a Physical Therapy diagnosis is not a medical diagnosis by a physician or based on radiological

imaging and such services might not be covered by your health plan or insurer.

At Motion Stability and Movement Sports Physical Therapy, we use a variety of procedures and modalities to help us

improve your function. As with all forms of medical treatment, there are benefits and risks involved with physical therapy.

Since the physical response to a specific treatment can vary widely from person to person, it is not always possible

to accurately predict your response to a certain modality or procedure. We are not able to guarantee precisely what your

reaction to a particular treatment might be, nor can we guarantee that our treatment will help the condition you are

seeking treatment for. There is also a small risk that your treatment may cause pain or injury, or may aggravate previous

existing conditions. You have the right to ask your physical therapist what type of treatment he or she is planning based

on your medical history, diagnosis, symptoms and testing results. You may ask your therapist as to the potential risks

and benefits of a specific treatment. You have the right to decline any portion of your treatment at any time before or

during your treatment session. Therapeutic exercises are an integral part of most physical therapy treatment plans.

Exercise has inherent physical risks associated with it. If you have any questions regarding the type of exercise you are

performing and any specific risks associated with your exercises, your therapist will be glad to answer them.

I acknowledge that my treatment program has been explained by Motion Stability and Movement Sports Physical

Therapy, and all of my questions have been answered to my satisfaction. I understand the risks associated with a

program of Physical Therapy as outlined to me, and wish to proceed.

EVERY PATIENT MUST RECEIVE A COPY OF THIS PAGE


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Notice of Patient Information PracticesTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR

DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO INFORMATION.PLEASE REVIEW IT CAREFULLY.

LEGAL DUTYMotion Stability is required by law to protect the privacy of your personal health information, provide this notice about our information practices, and follow the information practices that are described herein.

USES AND DISCLOSURES OF HEALTH INFORMATIONMotion Stability and Movement Sports Physical Therapy use your personal health information primarily for treatment, obtaining payment for treatment, conducting internal administrative activities, and evaluating the quality of care that we provide. For example, Motion Stability and Movement Sports Physical Therapy may use your personal health information to contact you to provide appointment reminders, or information about treatment alternatives or other health related benefits that could be of interest to you. Motion Stability and Movement Sports Physical Therapy may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law. In any other situation, Motion Stability and Movement Sports Physical Therapy’s policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time. Motion Stability and Movement Sports Physical Therapy may change its policies at any time. When changes are made a new Notice of Information Practices will be posted in a common area of our office. You may also request an updated copy of our Notice of Information Practices at any time.

PATIENT’S INDIVIDUAL RIGHTSYou have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment, or other related administrative purposes.

You may also request in writing that we not use or disclose you personal health information for treatment, payment, and administrative purposes except when specifically authorized by you, when required by law, or in emergency circumstances. Motion Stability and Movement Sports Physical Therapy will consider all such requests on a case-by-case basis, but the Company is not legally required to accept them.

CONCERNS AND COMPLAINTSIf you are concerned that Motion Stability or Movement Sports Physical Therapy may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact our office at the address listed below. You may also send a written complaint to the US Department of Health and Human Services. For further information on Motion Stability or Movement Sports Physical Therapy’s health information practices, or if you have a complaint, please contact the following office:

Motion Stability / Movement Sports Physical Therapy3280 Peachtree Road NE #160Atlanta, GA 30305(404) 382-8702

EVERY PATIENT MUST RECEIVE A COPY OF THIS PAGE


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Patient Information Consent Form

I, ______________________________ (Print Name), do hereby acknowledge that I have been given a copy of Motion Stability

and Movement Sports Physical Therapy’s Notice of Patient Information Practices and has been given the opportunity to ask

any questions that I may have regarding it.

________________________________________________________________________________________________________________

Signature Date

Access to Protected Health Information (PHI)I hereby authorize the following individual(s) to receive or discuss information pertaining to my medical condition(s), release

medical records, or discuss billing: Not Applicable

Name: ____________________________________ Relationship:_____________________

Name: ____________________________________ Relationship:_____________________

Patient Privacy NoticeHIPPA is an acronym for the Health Insurance Portability & Accountability Act of 1996 (Federal Law). Of significant concern to

healthcare organizations is the Administrative Simplification Section of the Act, which requires healthcare organizations to

comply with specific rules regarding:

• Unique Identifiers for health plans, providers, individuals, employers.

• Healthcare Transaction & Code Sets for transmitting date electronically.

• Privacy regulations over disclosure and use of health information.

• Security regulations over protections of electronic health information.

It is our policy to not release confidential and/or unauthorized information by home telephone, answering machine, work

telephone, voice mail, cell phone and/or pager. Whenever returning phone calls and the answering machine picks up, we will

not leave a message if the name or telephone number on the recorded message does not match your name or identity.

Information will also not be left with an unauthorized person who may answer the telephone. If you would like

to have information released to someone other than yourself please complete the following:

I, ______________________________(Print Name), hereby authorize Motion Stability and Movement Sports Physical Therapy’s

staff to leave medical information pertaining to my care by telephone, email or voicemail and will assume responsibility to

notify them whenever this information changes.

________________________________________________________________________________________________________________

Signature Date

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_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Account Balance

Please provide us, in the space below, the credit card information you would like to be used for remaining account balances or appointment cancellation charges. You will be contacted and notified before any charges are placed on the credit card. Please let us know if you have any questions regarding the above information.

Credit Card Number

Expiration Date 3-4 Digit Security Number

Name on Card (Print)

Signature Date

I agree to treatment on all the above terms

Cancellation Policy

A scheduled appointment must be cancelled at least 24 hours in advance or the patient will be charged $170.00 for that appointment.

3280 Peachtree Road NE, Suite 160, Atlanta, GA, 30305 | All Appointments: (404) 382-8702 | www.motionstability.com

MOTION STABILITY-PAYMENT POLICIES

Health Insurance Information

Motion Stability provides quality and individualized service through dedicated time between the patient and our Physical Therapists. In order to do so, Motion Stability is an out-of-network insurance provider.

As a courtesy, we will verify your out-of-network insurance benefits before your first evaluation, keeping in mind that it is still the patient’s responsibility to confirm and know their own policy benefits. We will also provide services by submitting the patient’s claims to their insurance company.

Once the patient’s deductible is satisfied, the patient will be responsible to pay an estimated coinsuranceamount at the time of the visit. The insurance company will be billed for our services, with the patient accepting responsibility for any uncovered amounts or balances.

Self-Pay (no insurance or self submission of insurance claims)

Initial Evaluation: $180.00 (per 55 minutes)Includes complete evaluation, diagnosis,and treatment.

Follow-up Treatments: $170.00 (per 55 minutes) or $85 (per 30 minutes) An itemized bill can be provided for you upon request.

Documents

Motion New Patient Packet 2015