Zada Rehab » New Patient Forms New Patient Forms New Patient Intake form New Patient Acknowledgement Medication List New Patient Acknowledgement Click here to open Patient Name(Required) Name Consent to Treatment(Required) I consent to and authorize Zada Rehab Occupational & Physical Therapy to administer rehabilitation therapy treatment. I understand and am informed that, as in the practice of medicine, rehabilitation therapy may have some risks. I understand that I have the right to ask about these risks and have any questions about my conditions answered prior to treatment. I know it is up to me to inform my provider of rehabilitation therapy about any health problems or allergies I have, as well as medications I am taking. I understand that the practice of rehabilitation therapy is not an exact discipline and I acknowledge that no guarantees have been made to me regarding treatment and/or treatment results from the rehabilitation therapy.Notice of Privacy Practices(Required) I hereby acknowledge that I have been made aware of Zada Rehab's Notice of Privacy Practices. I further acknowledge that a copy of the current notice is available at the front desk and online, and that I may request a copy of any amended Notice of Privacy Practices at any time.Authorization to Release/Obtain Information(Required) I hereby authorize the release of my patient health care information for the purpose of treatment or payment, to my physician, insurance company, adjustor, attorney, or other health care organizations pertinent to my case. Further, I authorize Zada Rehab to obtain needed information from my physician, insurance company, adjustor, attorney and any other health care organization pertinent to my case. These correspondence can be made via mailings, telephone and/or facsimile.Insurance Eligibility(Required) Verification of benefits is NOT a guaruntee of payment. Payment is determined by your insurance company at the time a claim is received. We provide you with the information as it is outlined by your insurance company. It is your responsibility to fully understand your insurance benefits.Financial Responsibility(Required) Payment is due at the time or treatment. I agree to pay Zada Rehab all amounts that are due for services rendered which are not otherwise paid for by my insurance plan on my behalf. In the event that my account is referred to a collection agency or an attorney, I further agree to pay all reasonable costs incurred to collect any amounts that are due for services rendered including, without limitation, reasonable attorney's fees.Assignment & Release of Benefits(Required) I hereby appoint Zada Rehab Physical Therapy as my authorized representative, and assign to it my right, to file for, receive and recover any and all monies payable for the care which it rendered to me from any third party claims payment source, including my health insurer, Medicare, Medicaid or other governmental program (collectively, my "Plan"), while I was eligible to receive such claim payment. I authorize you to send and receive documentation related to my treatment to, and consent to your discussing my treatment with, my "Plan." I also authorize PPT to take any and all actions necessary to assert and pursue my legal rights to receive such claim payment under the terms of my Plan through any appeals and/or grievances and/or litigation and/or arbitration available to me for such purpose. As the assignor of the foregoing payment amounts, I direct that such payment be sent by my Plan to PPT and, in the case that payment is made by my Plan to me, I agree to remit such payment in full to PPT not later than ten(10) days after my receipt.Appointments / Cancellations(Required) We advise you to schedule your appointments in advance. Maintaining a consistent schedule ensures your best outcome for a speedy recovery. We expect you to keep all of your appointments with Zada Rehab and require 24 hours notice if you are unable to keep an appointment. Failure to show up for an appointment will result in a $50.00 charge. These charges are not reimbursed by any insurance company.Electrical Stimulation Pad Policy(Required) I acknowledge that I have read and understand the Electrical Stimulation Pad Policy and agree to abide by its terms.The undersigned patient or Responsible Party acknowledges that he/she has read and agrees to the information above with e-signature.Name(Required) Full Name Date MM slash DD slash YYYY CAPTCHA Click here to Print Medication List Click here to open Name(Required) First Last Date MM slash DD slash YYYY Please list all your medications, including all prescriptions, over the counter medications, herbals, vitamins, minerals, and dietary supplements, and the dosage, frequency and administration method for each medication.Medication Dosage Frequency As Needed Once Daily Twice Daily Other Medicine Type Oral Sublingual Topical Subcutaneous Injection Other Medication Dosage Frequency As Needed Once Daily Twice Daily Other Medicine Type Oral Sublingual Topical Subcutaneous Injection Other Medication Dosage Frequency As Needed Once Daily Twice Daily Other Medicine Type Oral Sublingual Topical Subcutaneous Injection Other Medication Dosage Frequency As Needed Once Daily Twice Daily Other Medicine Type Oral Sublingual Topical Subcutaneous Injection Other Medication Dosage Frequency As Needed Once Daily Twice Daily Other Medicine Type Oral Sublingual Topical Subcutaneous Injection Other List other if applicableConsent(Required) I certify that the information I have provided above and/or on a separate document is complete, accurate and truthful to the best of my knowledge.CAPTCHA Click here to Print Click here to Print Click here to Print Medical History Credit Card Authorization Medical History Click here to Open Name(Required) First Last Condition Begin Date MM slash DD slash YYYY Work Status Full Time Part Time Off Duty On the job injury? Yes No How much does pain limit activity?Please enter a number from 0 to 100.%Rate your pain when symptoms at worst (0=no pain, 10 = worst pain you can imagine)012345678910Rate your pain when symptoms at best (0=no pain, 10 = worst pain you can imagine)012345678910Rate your pain today (0=no pain, 10 = worst pain you can imagine)012345678910Currently taking medications? Yes. If yes, please make sure to fill out the supplemental form to list all medications. Not currently taking any prescribed or over the counter medications, herbals, or vitamin/mineral/dietary/nutritional supplements. Past Surgical HistoryType of Surgery Date of Surgery Type of Surgery Date of Surgery Type of Surgery Date of Surgery Have you had any of the following diagnostic, medical, or rehabilitative services for this injury/episode? Chiropractor Practitioner EMG/NCV Massage Therapy CT Scan MRI Myelogram Neurologist Occupational Therapy Orthopedist Physical Therapy Podiatrist ER X-Rays Past Medical History: Please check any condition you currently have OR have ever had in the past. Asthma Anxiety Anemia Blood Clot Cancer Concussion Depression Diabetes Fibromyalgia Gout Heart Problems Hernia High Blood Pressure Infectious Diseases Migranes/Headaches Neurologic Disorder Osteoporosis Pacemaker Pins or Metal Implants Rheumatoid Arthritis Seizures Sleep Problems Stroke Thyroid Trouble/Goiter Varicose Veins Visual Dysfunction Please List All AllergiesHave you experienced any of these symptoms recently(please check all that apply) Chest Pain Pain with Meals Nausea/Vomiting Dizziness Vision Changes Memory Problems Unusual Weakness Poor Balance/Falls Fever/Chills/Sweats Difficulty Speaking Numbness/Tingling Change in Appetite Difficulty Swallowing Shortness of Breath Confusion/ Brain Fog Unusual Pain w/Menstruation Unexplained Weight Loss/Gain Increased Pain at Night/Rest Change in Bowel Habits/Control Change in Bladder Habits/Control Other Smoker Yes No If yes, packs per day?Alcohol Use Yes No If yes, drinks per day?Possibly Pregnant? Yes No Consent By my name below, I certify that the information I have providied above is complete, accurate and truthful to the best of my knowledge.Name (Parent/Guardian Name)(Required) First Last Date MM slash DD slash YYYY CAPTCHA Click here to Print Credit Card Authorization Click here to Open We are committed to meeting your healthcare needs and keeping your insurance and other financial arrangements as simple as possible. In order to accomplish this in a cost-effective manner for all our patients, we ask that you adhere to our practice's financial policy. By clicking to give your consent below, you are agreeing to its terms. 1.(Required) I am ultimately responsible for payment of charges for services I receive including those covered by my insurance. As a convenience, this practice will submit claims for reimbursement with my insurance provider; however, all payment responsibility is ultimately mine.2.(Required) Some immediate payment may be expected at the time of service. This may include a co-pay and additional payment if this practice determines that the cost of my visit today will not be reimbursed by my insurance provider. This often happens if my deductible is not yet satisfied.3.(Required) This practice may deny service or charge a service fee for failure to pay a co-pay or any outstanding balance at the time of service.4.(Required) It is my responsibility to provide my current address, telephone number, email address, and insurance information at each visit.5.(Required) I agree to provide the above practice and/or its designated payment agent with my debit/credit card information.6.(Required) I understand that my signature and payment information will be maintained on file for future use by the practice. The applicable payment card or bank account number will be truncated and "tokenized" by the payment agent in order to help maintain the security of my payment information.7.(Required) If warranted, this practice may offer the option of paying my share of costs via automated payment plan. I understand that I may incur some interest expense beyond my balance in exchange for this convenience. I can avoid interest charges by paying my bill immediately if required by its due date.8.(Required) I authorize the above practice and/or its designated payment agent to apply charges to my payment card and/or bank account for all amounts owed to the practice for medical visits, procedures or supplies, including (i) amounts agreed as part of a payment plan, (ii)copayments, (iii) coinsurance (after application of insurance proceeds), (iv) amounts not covered by insurance and/or (v) fees (if applicable) charged by the practice for failure to keep a scheduled appointment or provide timely notice of appointment cancellation.9.(Required) In the case of a patient balance that is not satisfied by a charge to my payment method or a payment plan, I may receive a mothly statement for any outstanding balance. I am responsible for paying this balance by its due date in order to avoid paying possible interst on the balance.10.(Required) I will not be provided with advance motice of payments authorized hereunder for tranactions up to an amount specified by me. I will be provided with a courtesy notification prior to processing any payment in excess of such amount. Transaction receipts will be maintained in the patient file or will be emailed to me if I provide and maintain a valid email address.11.(Required) I authorize the above practice and/or its designated provider to send electronic account statements and invoices to my email address on file. I understand that it is my responsibility to maintain a current email address on file and that I will not receive a mailed copy of any electronic statement.This authorization will remain in effect until I provide written notice of cancellation to the practice. Authorization for services already rendered cannot be cancelled or refunded. I agree to notify the practice in writing of any changes in my payment or other information.Cardholder Name (as it appears on card)(Required) Full name as appears on card Email of Cardholder PhoneCardholder Billing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Consent(Required) I agree to the above statements by clicking this box and using my name below as an e-signature.Name(Required) First Last CAPTCHACommentsThis field is for validation purposes and should be left unchanged. Click here to Print Click here to Print Click here to Print
