New Patient Center

MEDICAL HISTORY QUESTIONNAIRE

I grant permission and consent to be evaluated and receive treatment from a physical therapist at Physiopros Performance Rehab under a mutually agreed treatment plan for either short-term or ongoing treatment.

CONSENT TO RECEIVE MAIL, VOICEMAIL, EMAIL, OR TEXT MESSAGES

I confirm my permission for the following (check one for each):

CONSENT TO BE FEATURED ON SOCIAL MEDIA

I CONFIRM MY PERMISSION FOR THE FOLLOWING (PLEASE SELECT ONE)

If I grant consent to be featured on social media, I hereby waive all right of publicity, and any rights to be compensated by Physiopros Performance Rehab for any use of my image or likeness, or any use of my voice or video recordings of myself.

CONSENT TO RELEASE INFORMATION TO PERSONAL REPRESENTATIVE

I confirm my permission to share/discuss my medical, billing, and insurance information with the following people, and hereby waive any claims against Physiopros Performance Rehab that such a release is a violation of HIPAA.

I understand that I am waiving my rights to confidentiality throughout the course of treatment if I choose to provide any personal representatives.

The following information describes how your health information will be used and disclosed and how you can gain access to this information.

TREATMENT: Your information may be used by staff members or disclosed to other health care providers for the purposes of evaluation, diagnosing, developing treatment plans, and providing treatment.

Payment: Your health information may be used to seek payment from your health plan, from other sources of coverage, or from your credit/debit card company (if you choose to pay with card).

Health Care Operations: Your health information may be used to support management and operations at Physiopros Performance Rehab to evaluate and support budgeting, financial reporting, and promotion of quality care.

Law Enforcement: Your health information may be disclosed to law enforcement agencies to support government audits, facilitate investigations, and comply with mandated government reporting.

Public Health: Your health information may be disclosed/reported to public health agencies as required by law for certain communicable diseases.

ADDITIONAL USES OF INFORMATION: All other uses of your private health information require your prior written authorization. You may revoke this authorization at any time, but all information disclosed prior to the revocation will not be undone.

Appointment Reminders: Your health information may be used to send you appointment reminders.

Billing: Your health information may be used to collect payments.

Medical Records/Test Results: Your health information may be used to provide you with medical records or test results.

Marketing: Your health information may be used for marketing purposes including being featured on social media as well as promotional e-mails, mail, or newsletters that may be related to your condition.

INDIVIDUAL RIGHTS: The following list includes your rights as a patient in regards to your private health information usage/disclosures.

• The right to request restrictions on the usage and disclosure of your health information
• The right to receive confidential communications about your health information
• The right to inspect and copy your health information
• The right to amend or submit corrections to your health information
• The right to know who your protected health information is disclosed to and how it is used
• The right to receive a printed copy of this notice
• The right to submit a complaint to Physiopros about the use or disclosure of private health information at physiopros@physioprospt.com or by speaking with an employee at our front desk
• The right to request further information about our notice of privacy practices by emailing physiopros@physioprospt.com or speaking with an employee at our front desk

PHYSIOPROS DUTIES AND RIGHTS: The following list includes Physiopros Performance Rehab’s duties and rights in regards to your health information and our notice of privacy practices.

• We are required to maintain the privacy of your protected health information
• We are required to provide you with this notice
• We are required to abide by the policies in this notice
• We are required to notify you of any breach in your protected health information
• We have the right to make changes to this notice
• We are required to provide you with any changes to this notice
• We have the right to request you to provide a written request to inspect, receive, or copy your health information

HIPPA: I confirm that I have received, read, and understood a thorough notice of privacy practices describing how my health information may be used or disclosed in order to carry out treatment, billing/payment, and healthcare operations.

This policy has been established to help us serve our patients better. It is necessary for us to make appointments in order to see our patients as efficiently as possible. No-shows and late-cancellations cause problems that go beyond a financial impact on our practice. When appointments are made, they take available time slots away from other patients. Therefore, our policy is as follows:

A $50 fee will be applied when either one of these take place:

A “no-show” is missing a scheduled appointment

A “late-cancellation” is canceling an appointment without a 24hr advance notice. Please note that this excludes emergencies, illness and weather-related cancellations. We do encourage our patients to reschedule any missed appointments within the same week to ensure compliance with the treatment plan.