Patient Intake Form | Pro-Motion Physical Therapy

Patients
Authorizations

AUTHORIZATION FOR TREATMENT:

I voluntarily consent to physical therapy care encompassing evaluation and treatment procedures. I acknowledge that no guarantees have been made to me about the results of the exam and/or treatments to be provided in this healthcare facility. I authorize Pro-Motion Phyiscal Therapy to provide such treatment.

Initials^*

PAYMENT AUTHORIZATION:

I request that payment be made on my behalf to Pro-Motion Physical Therapy for services furnished to me by Pro-Motion Physical Therapy. I authorize Pro-Motion Physical Therapy to release to the Centers for Medicare & Medicaid Services and its agents, any state Medicaide agency, and any other third party payor all medical or other information that is needed to determine the benefits payable for health services. I agree to pay the charges for the care and treatment rendered to me that are not covered by insurance including any reasonable collection fees required to collect delinquent accounts. MY HEALTHCARE PROVIDER, INSURER, OR PLAN MAY REQUIRE A PHYSICIAN REFERRAL OR PRIOR AUTHORIZATION AND I MAY BE OBLIGATED FOR PARTIAL OR FULL PAYMENT OF PHYSICAL THERAPY SERVICES RENDERED.

Initials^*

RECORD RELEASE:

I hereby authorize Pro-Motion Physical Therapy to release any/all medical information acquired in the course of treatment to myself, my insurance company, employer, or other healthcare agencies, professionals, or persons who may provide healthcare services deemed necessary for continuing my medical care.

Initials^*

NAME

RELATIONSHIP

PHONE NUMBER

HIPAA PRIVACY POLICY:

I have been provided a copy of the HIPAA Privacy Policy for review and know that if I would like a copy of it to keep, I have requested one.

Initials^*

CANCEL/NO SHOW POLICY:

I have read and understand Pro-Motion Physical Therapy’s Cancellation and No Show Policy and know that if I would like a copy of it to keep, I have requested one.

Initials^*

On behalf of Pro-Motion Physical Therapy, we thank you for trusting us with your medical care and rehabilitation. When you schedule an appointment with Pro-Motion Physical Therapy, we promise to provide you with the highest quality care. In order for us to make this possible, we have established a strict policy regarding late cancellations, no shows, and late arrivals (effective October 1, 2022). Although we understand that emergencies and illnesses arise, cancellations made with less than 24 hours’ notice significantly limits our ability to make the appointment available for another patient in need.

“Late Cancellations” are any scheduled appointments that are cancelled with less than 24 hours notice, prior to the appointment time. This means that an appointment that is scheduled at 8 AM must be cancelled NO LATER than 8 AM the previous morning, to avoid a late fee. “No Shows” are appointments that are scheduled, that are not cancelled, where the patient fails to arrive. “Late Arrivals” is any patient that arrives at our clinic 15 minutes or more after their expected arrival time for their scheduled appointment.

Pro-Motion Physical Therapy No Show/Cancellation/Late Arrival Policy:

Any established patient who fails to show or cancels/reschedules an appointment with less than 24 hours’ notice will be considered a No Show and will be charged a $40.00 fee.
In the event a patient has three (3) documented no shows and/or same day cancellations, the patient may be dismissed from Pro-Motion Physical Therapy, at the discretion of the Therapist.
Any patient that arrives 15 or more minutes after their scheduled appointment time will be rescheduled and will be considered a No Show.
Any patient that fails to show for their initial visit will not be rescheduled.
All fees will be charged directly to the patient and will be 100% the patient’s financial responsibility. None of our No Show/Cancellation/Late Arrival fees can be billed to the patient’s insurance. These fees will be due at the time of the patient’s next office visit.
As a courtesy, Pro-Motion Physical Therapy makes reminder calls for appointments. If you do not receive a reminder call or message, the above policy will remain in effect.

You may contact Pro-Motion Physical Therapy 24 hours a day, 7 days a week at the numbers below. Should it be after regular business hours or a weekend, you may leave a message.

Pro-Motion Physical Therapy

(509) 573-4816

I have read and understand the No Show/Cancellation/Late Arrival Policy and agree to the above terms

PATIENT PRINTED NAME^*:

DATE^*:

PATIENT/REPRESENTATIVE/
PARENT/LEGAL GUARDIAN SIGNATURE:

IF SIGNED BY PATIENT REPRESENTATIVE OR PARENT/LEGAL GUARDIAN, INDICATE RELATIONSHIP TO PATIENT:

CANCELATION AND NO SHOW
Policy

OUR POLICY:

We are sincerely concerned with helping you meet your goals of therapy. In order to do this, it is important that you attend all scheduled therapy appointments. Consistent attendance allows you and your therapy team to progress your treatment program which will result in a quicker recovery and better outcomes.

We realize that there are times when unforseen circumstances make it impossible to attend your scheduled appointment. If this happens, please give us as much notice as possible so we can reschedule the time for another patient and find another time for your appointment. Canceling an appointment with short notice or not showing up for an appointment takes up clinic time that could benefit another person.

Please review the following policy, sign below and return to the front office staff. Should you have any further questions, please consult with your therapist.

Thank you for your cooperation.

Please read the following Cancelation and No Show Policy carefully and initial next to each item.

If you cannot make it to your appointment, please contact our office at least 24 hours in advance to cancel your appointment.

Our late cancelation fee is $40.

If you miss 3 appointments without proper notice, all future appointments will be canceled. You must pay any fees prior to additional visits Once fees are paid, you will be able to schedule 2 appointments at a time.

No fees will be waived. Special circumstances will be handled on a case-by-case basis. If you intend to dispute the charge, you should speak with our Financial Officer the next appointment.

Patient Name^*:

Patient Signature^*:

Date^*:

I have read the above information and understand the attendance policy and my role in my rehabilitation program. All the information provided to Pro-Motion Physical Therapy is correct to the best of my knowledge.

I agree to the terms and conditions^*

Demographics Records

PATIENT INFORMATION

APPOINTMENT REMINDERS

INSURANCE INFORMATION

Patients
Authorizations

AUTHORIZATION FOR TREATMENT:

PAYMENT AUTHORIZATION:

RECORD RELEASE:

HIPAA PRIVACY POLICY:

CANCEL/NO SHOW POLICY:

Patient Intake
Questionnaire

ABOUT YOUR CURRENT COMPLAINT:

ABOUT YOUR GENERAL HEALTH:

CANCELATION AND NO SHOW
Policy

OUR POLICY:

Demographics Records

PATIENT INFORMATION

APPOINTMENT REMINDERS

INSURANCE INFORMATION

PatientsAuthorizations

AUTHORIZATION FOR TREATMENT:

PAYMENT AUTHORIZATION:

RECORD RELEASE:

HIPAA PRIVACY POLICY:

CANCEL/NO SHOW POLICY:

Patient Intake Questionnaire

ABOUT YOUR CURRENT COMPLAINT:

ABOUT YOUR GENERAL HEALTH:

CANCELATION AND NO SHOWPolicy

OUR POLICY:

Patients
Authorizations

Patient Intake
Questionnaire

CANCELATION AND NO SHOW
Policy