new patient forms · 2 days ago · ¨ new patient forms. kindly download, complete, print or email...

WELCOME New Patient Forms

¨ We have 2 therapy centers, one in Burbank and one in Glendale.

¨ New Patient Forms. Kindly download, complete, print or email [email protected] for the Burbank center, [email protected] for the Glendale center and in subject, kindly type: New Patient Forms. Note: Your insurance and the type of injury may require that you complete additional forms in our office.

¨ Referral. Bring a prescription or referral form from the doctor who is referring you to physical or hand therapy. The prescription / referral form must include the doctor name, the office telephone number and your diagnosis. Most insurance companies do require a prescription. You may be able to receive physical therapy services for a short duration without a prescription; however, if you are using health insurance, we highly RECOMMEND you present the prescription / referral from the start.

¨ We accept various forms of payment (cash, check, credit card).• If you have health insurance, bring your insurance card.• If your injury is related to a Workers’ Compensation claim, have ready the claim number

and your case manager’s name, telephone and email.

¨ Understand that before your first appointment, our Insurance Verification Coordinator will verify your insurance benefits related to your therapy treatments and will verify the estimated costs.Questions? Call the therapy center - Burbank: (818) 579-2370; Glendale: (818) 579-2395.

¨ Day of:• We are committed to everyone’s safety regarding Covid-19. You must wear a mask in

our office. If you have signs or symptoms of an upper respiratory infection (e.g., fever, cough, sore throat, shortness of breath, and/or body aches) or have been in contact with a person with these symptoms or have recently traveled to a high-risk zone, you MUST reschedule your appointment. Ask us about our telehealth visits if you cannot make an on-site appointment or if you are high risk for Covid-19.

• Wear loose and comfortable clothes. Examples: shorts, sweats and t-shirt.• Bring a valid photo ID.

¨ If you need to cancel or reschedule, please give us at least 24 hours’ notice. (Again, if you have had exposure to Covid-19, please see your primary care doctor and reschedule your on-site appointment with us.)

¨ If you have any questions or want to know what to expect on your first visit, see our FAQ page on our website.

1 ossphysicaltherapy.com New Patient Forms


OSS Physical & Hand Therapy, Burbank Center 2701 W. Alameda Ave, Suite 206 | Burbank, CA 91505 T: (818) 579-2370 | F: (818) 579-2371| [email protected]

An aerial view to find us.

Your parking options: • 2701 Parking Garage & Handicap Parking. Pay by cash or credit card only.

Every 15 minutes is $1; 2 or more hours is $9. Please note we do not validate or reimburse for parking. • 2625 Parking Garage. Pay by credit card.

Every 10 minutes is $1; Max $9. Please note we do not validate or reimburse for parking. • Free 2-hour street parking.



OSS Physical & Hand Therapy, Glendale Center 1300 S. Central Ave. | Glendale, CA 91204 T: (818) 579-2395 | F: (818) 579-2396 | [email protected]

An aerial view to find us.

Street parking is available around the building.


PATIENT INFORMATION

First Name Last Name MI

Mailing Address

City State Zip Code

Cell Phone Home Phone Work Phone

DOB Age Sex ❍ Female ❍ Male SSN#

Marital Status ❍ Married ❍ Single ❍ Divorced ❍ Widow ❍ Domestic Partner

Email Address

Employer Name Occupation

Is this injury work-related? ❍ Yes ❍ No Is this injury related to an auto accident? ❍ Yes ❍ No Do you have Medical Insurance? ❍ Yes ❍ No

Do you have Medicare? ❍ Yes ❍ No

In case of emergency, please notify: Name Phone Relationship

Responsible for payment (if other than patient; i.e., Parent, Spouse, Guardian): Name of Responsible Party

Mailing Address of Responsible Party

City State Zip Code

Cell Phone Home or Work Phone

Name of Medical Insurance Company (PRIMARY)

Name of Medical Insurance Company (SECONDARY)

Policy Holder Name Policy Holder DOB

Referring Physician

Is this injury related to a Workers' Comp claim? Yes No


Health Indicators Screening

Our physical and hand therapists are required to screen you for various health indicators (as of 2015). The categories include tobacco and alcohol use, body mass index, medications, and fall risk. It is your choice to refrain from answering questions, although OSS Physical & Hand Therapy feel that it is in your best interest to do so.

First Name __________________ Last Name _________________________ Middle Initial ______

Body Mass Index

Weight_______ lbs. Height _______feet _______inches

Tobacco

Are you a smoker or tobacco user? Yes No

Alcohol Consumption in Past Year

Did you have a drink containing alcohol in the past year? Yes No

If yes, how often in the past year? Never Monthly

or less 2 to 4 times

a month 2 to 3 times

a week 4 or more

times a week

If yes, how many drinks did you have a on a typical day? 1 or 2 3 or 4 5 to 6 7 to 9 10

If yes, how often did you have 6 or more drinks on one occasion in the past year? Never Less than

monthly Monthly Weekly Daily or almost daily

If you are 65 years and older, please answer

Have you fallen 2 or more times in the past 12 months? Yes No Have you had a fall in the past 12 months that resulted in an injury? Yes No Do you have an advance care plan or surrogate decision maker? Yes No


HISTORY & PHYSICAL

Name

Reason for visit

Date of original symptoms/accident/surgery

Describe your symptoms

List any diagnostic testing (X-Ray, MRI, CT)

List any previous treatment of this issue

Describe your pain (1-10 rating) ❍ 1 ❍ 2 ❍ 3 ❍ 4 ❍ 5 ❍ 6 ❍ 7 ❍ 8 ❍ 9 ❍ 10

Describe your pain: ❍ Constant ❍ Frequent ❍ Occasional ❍ Intermittent

Have your symptoms changed in the last 4 weeks? ❍ Yes, they have improved ❍ No, there has been no change ❍ Yes, they are getting worse

What sports or other activities do you participate in?

List any significant prior surgeries or injuries

Please mark any you the following that you have or have had: Please shade in painful areas below

I agree that the above information is correct and true to the best of my knowledge.

❍ Chest pain (Angina)

❍ Heart Attack or Surgery

❍ Rheumatic Fever

❍ Pacemaker

❍ Emphysema, Bronchitis

❍ Pregnancy

❍ Diabetes

❍ Cancer

❍ Stroke

❍ Nervous Disorders

❍ Osteoporosis

❍ Liver Problems

❍ Arthritis

❍ Artificial Joints

❍ Frequent Headaches

❍ Epilepsy or Seizures

❍ Kidney Problems

❍ High blood pressure

❍ Reactions to Heat/Cold

❍ Metal anywhere in your body

❍ Unexplained weakness, weight change, or shortness of breath

❍ Immune Deficiency Disease

❍ Hernia

❍ Dizziness/Fainting

❍ Fever/Chills

❍ Nausea/Vomiting

❍ MRSA or any Infectious Disease

❍ Difficulty with bowel & bladder function

❍ Problems with vision, hearing, speech

❍ Numbness in genital area/anal area

❍ Night sweats/night pain

❍ Other ________________________________________

__________________________________________________

10 = EXCRUCIATING PAIN1 = NO PAIN 5 = MODERATE PAIN

Signature Date

X

Acct No.

Date of Birth

Do you have any allergies? If yes, please list:


Medication/Vitamin/Supplement Dose Freq Method(Pill, shot, drops, etc)

Timeof Day

Any change since seeing MD

Date of Change

MEDICATION RECORD

I certify that this information is complete and true. I acknowledge that nondisclosure of medicinal information could directly impact my health and services I receive. I further accept full responsibility in updating my therapist should any changes be made to my medicinal regimen.

It's a joint effort in making sure your medication list is current. In the event that your medication changes, please inform us as this information needs to be recorded each visit.

Signature Date

X


CLINIC POLICIES

Following are OSS Physical & Hand Therapy office policies concerning your account and schedule:

• Claims will be billed to your insurance carrier, but all charges incurred will be the responsibility of the patient. Verification of benefits is not a guarantee of payment by the insurance company.

• The adult or parent accompanying a minor is financially responsible for all services provided by OSS Physical & Hand Therapy.

• Co-payments, co-insurance, and deductibles are due at the time of service. We accept cash, check, Visa, Discover,American Express and MasterCard. We accept prepayment for co insurance and deductibles. Any overpayments will be reimbursed after the account is settled with insurance and patient has ceased treatment for 90 days.

• If payment is made by check, and the check is returned for Non-Sufficient Funds (NSF) or Account Closure (AC), the patient or patient's responsible party will be responsible for the original check amount in addition to a $25 service fee. Once notified by our office, payment must be made within 15 days, or the account may be turned over to our collection agency. _____________ (Please initial)

• Patients are responsible for notifying the front office of any changes regarding mailing address, phone number, and insurance coverage during or after the course of treatment.

• If claims are not paid by your insurance plan within 90 days, the overdue amount will become the full responsibility ofthe patient and payment will be due at that time. It is the patient's responsibility to resolve outstanding issues with their insurance carrier and receive reimbursement, if applicable.

• We require a 24 hour notice to change or cancel a scheduled appointment. We charge $25 for each missedappointment and/or late cancellation. This fee is subject to increase for multiple occurrences. This charge will notbe billed to your insurance company and payment is due before your next appointment. _____________ (Pleaseinitial)

• OSS Physical & Hand Therapy does not accept liens or other third-party payers.

• Unresolved financial disputes for non-payment of fees for services rendered will result in discontinuation of services. The patient may be referred to another provider as necessary.


Authorization & Agreements

Authorization and Assignments

I hereby authorize OSS Physical & Hand Therapy to release information necessary to my insurance company in order to process claims for charges incurred by me, and I release OSS Physical & Hand Therapy of any consequences thereof. In consideration of the services rendered to me by OSS Physical & Hand Therapy, I authorize and direct any insurance carrier to remit payment directly to OSS Physical & Hand Therapy.

Signature: Date:

Agreement to Pay for Services Rendered

My signature below verifies that I have read and agree to the stated Clinic Policies, including an understanding that: Regardless of insurance coverage, I am responsible and liable for payment of all charges assessed for professional services rendered and any fees charged due to my failure to follow the stated Clinic Policies. I am responsible for any balance that my insurance company has not paid within 90 days. In the event that my insurance company remits payment to me for services rendered by OSS Physical & Hand Therapy, I will promptly forward payment to OSS. If it becomes necessary for OSS Physical & Hand Therapy to commence legal action for collection of any outstanding charges on my account, I will be responsible for all reasonable fees incurred to collect said charges including collection fees, court costs, and attorney fees.

Signature: Date:

Insurance Benefits Acknowledgement

I have been made aware of my insurance benefits based on the information provided by my insurance company.

Signature: Date:

Privacy Practice Agreement

By signing this form, you are only acknowledging that you have been provided access to our notice.

Signature: Date:


00_C__OSS_PH HT New Patient Forms01_Welcome Letter03_Health Indicators Screening PT HT07_Authorization and Agreement08_Medicare Beneficiaries

Working2021_01_16_A_OSS PH HT New Patient Forms.pdf2021_01_16_New Patient Form_OSS PH HT2021_01_15_OSS Physical Hand Therapy New Patient Forms.pdf2021_01_15.pdf2020_12_8_A_OSS PT HT.pdf2020_12_08_OSS PT HT New Patient Forms.pdf

Middle Initial: Weight: Height: feet: Check Box1: OffCheck Box2: OffCheck Box3: OffCheck Box4: OffCheck Box5: OffCheck Box6: OffCheck Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box11: OffCheck Box12: OffCheck Box13: OffCheck Box14: OffCheck Box15: OffCheck Box16: OffCheck Box17: OffCheck Box18: OffCheck Box19: OffCheck Box20: OffCheck Box21: OffCheck Box22: OffCheck Box23: OffCheck Box24: OffCheck Box25: OffFirst Name: Last Name: MI: Mailing Address: City: State: Zip Code: Cell Phone: Home Phone: Work Phone: DOB: Age: Sex: OffSSN: Marital Status Married Single Divorced Widow Domestic Partner: undefined: Offundefined_2: Offundefined_3: Offundefined_4: Offundefined_5: OffEmail Address: Employer Name: Occupation: Is this injury workrelated: OffIs this injury related to an auto accident: OffDo you have Medical Insurance: OffDo you have Medicare: OffIn case of emergency please notify Name: Phone: Relationship: Responsible for payment if other than patient ie Parent Spouse Guardian Name of Responsible Party: Mailing Address of Responsible Party: City_2: State_2: Zip Code_2: Cell Phone_2: Home or Work Phone: Name of Medical Insurance Company PRIMARY: Name of Medical Insurance Company SECONDARY: Policy Holder Name: Policy Holder DOB: Referring Physician: Acct No: Name: Reason for visit: Date of original symptomsaccidentsurgery: Describe your symptoms: List any diagnostic testing XRay MRI CT: List any previous treatment of this issue: 10 EXCRUCIATING PAIN: OffDescribe your pain Constant Frequent Occasional Intermittent: undefined_8: Offundefined_9: Offundefined_10: Offundefined_11: OffHave your symptoms changed in the last 4 weeks: OffWhat sports or other activities do you participate in: List any significant prior surgeries or injuries: Please mark any you the following that you have or have had: OffLiver Problems: OffArthritis: OffArtificial Joints: OffFrequent Headaches: OffEpilepsy or Seizures: OffKidney Problems: OffHigh blood pressure: OffReactions to HeatCold: OffMetal anywhere in your body: OffUnexplained weakness weight change: OffImmune Deficiency Disease: OffHernia: OffDizzinessFainting: OffFeverChills: OffNauseaVomiting: OffMRSA or any Infectious Disease: OffDifficulty with bowel bladder function: OffProblems with vision hearing speech: OffNumbness in genital areaanal area: OffNight sweatsnight pain: OffOther: Offundefined_12: undefined_13: Are you taking any medications If yes please list on medication profile: Do you have any allergies If yes please list: Do you have any allergies If yes please list_2: Text8: MedicationVitaminSupplementRow1: DoseRow1: FreqRow1: Method Pill shot drops etcRow1: TimeRow1: Any change sinceRow1: DOSRow1: InitialsRow1: MedicationVitaminSupplementRow2: DoseRow2: FreqRow2: Method Pill shot drops etcRow2: TimeRow2: Any change sinceRow2: DOSRow2: InitialsRow2: MedicationVitaminSupplementRow3: DoseRow3: FreqRow3: Method Pill shot drops etcRow3: TimeRow3: Any change sinceRow3: DOSRow3: InitialsRow3: MedicationVitaminSupplementRow4: DoseRow4: FreqRow4: Method Pill shot drops etcRow4: TimeRow4: Any change sinceRow4: DOSRow4: InitialsRow4: MedicationVitaminSupplementRow5: DoseRow5: FreqRow5: Method Pill shot drops etcRow5: TimeRow5: Any change sinceRow5: DOSRow5: InitialsRow5: MedicationVitaminSupplementRow6: DoseRow6: FreqRow6: Method Pill shot drops etcRow6: TimeRow6: Any change sinceRow6: DOSRow6: InitialsRow6: MedicationVitaminSupplementRow7: DoseRow7: FreqRow7: Method Pill shot drops etcRow7: TimeRow7: Any change sinceRow7: DOSRow7: InitialsRow7: MedicationVitaminSupplementRow8: DoseRow8: FreqRow8: Method Pill shot drops etcRow8: TimeRow8: Any change sinceRow8: DOSRow8: InitialsRow8: MedicationVitaminSupplementRow9: DoseRow9: FreqRow9: Method Pill shot drops etcRow9: TimeRow9: Any change sinceRow9: DOSRow9: InitialsRow9: MedicationVitaminSupplementRow10: DoseRow10: FreqRow10: Method Pill shot drops etcRow10: TimeRow10: Any change sinceRow10: DOSRow10: InitialsRow10: MedicationVitaminSupplementRow11: DoseRow11: FreqRow11: Method Pill shot drops etcRow11: TimeRow11: Any change sinceRow11: DOSRow11: InitialsRow11: MedicationVitaminSupplementRow12: DoseRow12: FreqRow12: Method Pill shot drops etcRow12: TimeRow12: Any change sinceRow12: DOSRow12: InitialsRow12: MedicationVitaminSupplementRow13: DoseRow13: FreqRow13: Method Pill shot drops etcRow13: TimeRow13: Any change sinceRow13: DOSRow13: InitialsRow13: MedicationVitaminSupplementRow14: DoseRow14: FreqRow14: Method Pill shot drops etcRow14: TimeRow14: Any change sinceRow14: DOSRow14: InitialsRow14: Text9: initial 1: initial 2: Text32: Group34: OffText35: Text36: Text37: Text38:

new patient forms · 2 days ago · ¨ new patient forms. kindly download, complete, print or email...

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