Patient Forms Step 1 of 11 9% PATIENT INFORMATIONName* First Middle Last Date of Birth* Date Format: MM slash DD slash YYYY Last 4 Digits of Social Security #*Gender*MaleFemalePatient NicknameAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Primary Contact #*Cell #*Email Address* OccupationEmployer name and addressIf none, enter the word NoneEmployer phone #* CONSENT TO TREAT AND CONDITIONS OF ADMISSION 1 CONSENT TO REHABILITATION PROCEDURES: The undersigned consents to the procedures which may be performed during this and future out patient physical therapy visits that are performed at Baudry Therapy Center. I/We consent to examination, therapy procedures and therapy care given the patient by or under the supervision of the physical therapist. 2 LEGAL RELATIONSHIP BETWEEN FILL IN YOUR NAME HERE THERAPY PHYSICAL THERAPISTS: All Physical Therapists (PT), and Physical Therapist Assistants (PTA) are employed by Baudry Therapy Center. Baudry Therapy Center serves as a medical teaching facility; therefore, physical therapist students, physical therapist assistant students and physical therapy residents may be involved in your care under the supervision of an attending PT or PTA. 3 FINANCIAL AGREEMENT: The undersigned agrees whether he/she signs as agent or as patient, that in consideration of the services to be rendered to the patient, he/she hereby individually obligates himself/herself to pay the account of Baudry Therapy Center in accordance with the regular rates and terms of Baudry Therapy Center. All accounts are handled by our billing staff, including billing, collections and all other matters relating to the account. 4 ASSIGNMENT OF INSURANCE BENEFITS: The undersigned authorizes, whether he/she signs as agent or as patient, direct payment to Baudry Therapy Center of any insurance or other applicable (e.g., Medicare, BCBS) benefits otherwise payable to or on behalf of the undersigned or patient for these outpatient services, at rate not to exceed Baudry Therapy Center’s regular charges. It is agreed that payment to Baudry Therapy Center, pursuant to the authorization, by an insurance company shall discharge said insurance company of any and all obligations under a policy to the extent of such payment. Any pre-certification of insurance benefits is the patient’s sole responsibility; however, Baudry Therapy Center will make every effort to get this as a courtesy to the patient. The undersigned authorizes payment of Medicare benefits to be made on behalf of the patient for all services furnished by Baudry Therapy Center. It is further understood by the undersigned that he/she is financially responsible for charges not collected by this agreement, unless otherwise stated by applicable written contract or law. 5 PHOTOGRAPHING AND VIDEOTAPING: Baudry Therapy Center may photograph, film, videotape or otherwise make video and/or audio recordings of the patient only for purposes of diagnosing and treating the patient’s condition. No photograph or videotape will be used for any other purpose other than treatment without the patient’s written consent. 6 DISCLOSURE OF HEALTH INFORMATION: I understand that Baudry Therapy Center is a health provider who must comply with the Health Insurance Portability and Accountability Act of 1996. HIPAA protects the privacy of individually identifiable health information. The Baudry Therapy Center Notice of Privacy Practice outlines your rights and our responsibilities regarding your medical information and who to contact if you have any concerns regarding your medical information. Your initials below acknowledge that you have been given a copy of the Baudry Therapy Center Notice of Privacy Practices. Patient's Initials*Date* Date Format: MM slash DD slash YYYY 7. HOME EXERCISE PROGRAM AND APPOINTMENT REMINDERS: Baudry Therapy Center/BRIO utilizes secured email and text messaging communications to provide patients with home exercise programs and appointment reminders. I consent by providing the contact information in this form. Please initial to indicate your acceptance.Your Initials* INSURANCE INFORMATIONPrimary Insurance:Primary Insurance Company*Insured’s ID Number*Insured’s Policy Group #*Insured’s Name*Insured’s Address (if different) Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Insured’s Phone #*Insured’s Birth Date* Date Format: MM slash DD slash YYYY Insured’s Gender*MaleFemaleInsured’s Employer*If none, enter the word NoneYour Relation to Insured* Secondary Insurance:Insured’s ID NumberInsured’s Policy Group #Insured’s NameInsured’s Address (if different) Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Insured’s Phone #Insured’s Birth Date Date Format: MM slash DD slash YYYY Insured’s GenderMaleFemaleInsured’s EmployerIf none, enter the word NoneYour Relation to InsuredINJURY DETAILSMy injury is employment relatedYesNoMy injury is related to an accidentYesNoIf yes - please specify the type of accident:Motor vehicle accidentDate of injury Date Format: MM slash DD slash YYYY Give details of accidentI authorize the release of any medical or other information necessary to process insurance claims. I authorize payment of medical benefits directly to this practice for the services rendered. Patient/Guardian signature*Date of Signature* Date Format: MM slash DD slash YYYY BAUDRY THERAPY CENTER MEDICAL HISTORY FORMPlease complete this form in its entirety. If you don’t understand a question, please leave it blank and your therapist will assist you with that question. Thanks!Name*Age*Please enter a number from 0 to 120.Date of Birth* Date Format: MM slash DD slash YYYY Primary Care Physician/Family Physician*Date of Last Exam* Date Format: MM slash DD slash YYYY Leisure activities, including exercise routinesOccupation*Are you on a work restriction from your doctor?*YesNoAre you latex sensitive?YesNoDo you have a pacemaker?*YesNoPlease list any known medication allergies*FOR WOMEN: Are you currently pregnant or think you might be pregnant?*YesNoHave you RECENTLY noted any of the following (check all that apply) Fatigue Fever/chills/sweats Nausea/vomiting Weight Loss/gain Falls Weakness Numbness Or Tingling Difficulty Balancing Skin Rash Dizziness Diarrhea Fainting Constipation Bowel/bladder Changes Difficulty Swallowing Shortness Of Breath Regular Cough Headaches Tremors Seizures Double Vision Loss Of Vision Eye Redness Night Sweats Problems Sleeping Sexual Difficulties Hearing Problems Joint Swelling Easy Bruising Excessive Bleeding Difficulty Breathing Arm/leg Swelling Heart Racing Difficulty Swallowing Frequent Heartburn Blood In Stools Menopause Urinary Incontinence Problems Urinating Blood In Urine Significant Stress Have you EVER been diagnosed with any of the following conditions? (check all that apply) Cancer Heart problems Chest pain/angina High blood pressure Circulation problems Blood clots Stroke Anemia Chemical dependency Depression Emphysema/Bronchitis Tuberculosis Asthma Rheumatoid arthritis Other arthritic condition Incontinence Thyroid problems Diabetes Osteoporosis Bladder/Urinary infection Fractures Multiple sclerosis Epilepsy Kidney problems Stomach Ulcers Liver problems Hepatitis Other You selected Other, please explainDate of injury/onset of current symptoms* Date Format: MM slash DD slash YYYY Date of surgery, if any Date Format: MM slash DD slash YYYY What do you think caused your symptoms?*Please check any of the following services that you are receiving currently: Physical Therapy Occupational Therapy Chiropractic Care Massage Therapy Speech Therapy Dental Care Psychologist Have you had any of the following for your current problem: X-Ray Injection MRI CT Scan Other You selected Other, please explainHave you ever had this problem before?*YesNoIf yes, when?*In your current living environment do you have stairs?*YesNoIn your current living environment do you live alone?*YesNoHow would you rate your overall quality of life?*ExcellentGoodFairPoorDuring the past month have you been feeling down, depressed or hopeless?*YesNoDuring the past month have you been bothered by having little interest or pleasure in doing things?*YesNoDo you ever feel unsafe at home or has anyone hit you or tried to injure you in any way?*YesNoFamily history:Has anyone in your immediate family (parents, brothers, sisters) ever been treated for any of the following? (Check All That Apply) Diabetes Tuberculosis Heart Disease High Blood Pressure Arthritis Stroke Kidney Disease Alcoholism Cancer Anemia Headaches Epilepsy Mental Illness Depression Surgical history: Please list any surgeries or other conditions for which you have been hospitalized, including the approximate date and reason for the surgery or hospitalization:Surgery #1 Date Date Format: MM slash DD slash YYYY Surgery #1 ReasonSurgery #2 Date Date Format: MM slash DD slash YYYY Surgery #2 ReasonSurgery #3 Date Date Format: MM slash DD slash YYYY Surgery #3 ReasonSurgery #4 Date Date Format: MM slash DD slash YYYY Surgery #4 ReasonInjury history: Please list any significant injuries for which you have been treated including the approximate date:Injury #1 Date Date Format: MM slash DD slash YYYY Injury #1 ReasonInjury #2 Date Date Format: MM slash DD slash YYYY Injury #2 ReasonInjury #3 Date Date Format: MM slash DD slash YYYY Injury #3 ReasonInjury #4 Date Date Format: MM slash DD slash YYYY Injury #4 Reason Other Information:Do you smoke?YesNoIf yes, how many packs of cigarettes do you smoke in a day?*For how many years have you smoked?*If you have quit smoking when did that occur?Do you drink alcohol?YesNoIf yes how much do you drink in an average sitting?*(One drink equals one beer or glass of wine)How many days per week do you drink?*How many caffeinated coffee or other caffeine containing beverages do you drink per day?(8 oz = 1 drink)Medication Assessment: Please list all medications you are currently taking (including pills, injections, over the counter, skin patches, vitamins, herbs, etc): If you have a complete list from your doctor, feel free to provide it to us instead of completing the list below. Which of the following have you taken in the past week?Aspirin prescribed by a physician?*YesNoAspirin NOT prescribed by a physician?*YesNoAspirin Dosage*Aspirin Frequency*Tylenol prescribed by a physician?*YesNoTylenol NOT prescribed by a physician?*YesNoTylenol Dosage*Tylenol Frequency*Antiinflammatories (Advil, Motrin, Ibuprofen) prescribed by a physician?*YesNoAntiinflammatories (Advil, Motrin, Ibuprofen) NOT prescribed by a physician?*YesNoAntiinflammatories (Advil, Motrin, Ibuprofen) Dosage*Antiinflammatories (Advil, Motrin, Ibuprofen) Frequency*Stomach Ulcer Medications prescribed by a physician?*YesNoStomach Ulcer Medications NOT prescribed by a physician?*YesNoStomach Ulcer Medications Dosage*Stomach Ulcer Medications Frequency*Vitamins, Mineral Supplements prescribed by a physician?*YesNoVitamins, Mineral Supplements NOT prescribed by a physician?*YesNoVitamins, Mineral Supplements Dosage*Vitamins, Mineral Supplements Frequency*Herbal Remedies prescribed by a physician?*YesNoHerbal Remedies NOT prescribed by a physician?*YesNoHerbal Remedies Dosage*Herbal Remedies Frequency*Other Medications prescribed by a physician?*YesNoOther Medications NOT prescribed by a physician?*YesNoOther Medications Names*Other Medications Dosage*Other Medications Frequency* Please list any other physician prescribed medication you are currently taking (including pills, injections and/or skin patches):#1 Physician Prescribed Medication#1 Physician Prescribed Medication Dosage*#1 Physician Prescribed Medication Frequency*#1 Physician Prescribed Medication Route of Administration*MouthInjectionPatch#2 Physician Prescribed Medication#2 Physician Prescribed Medication Dosage*#2 Physician Prescribed Medication Frequency*#2 Physician Prescribed Medication Route of Administration*MouthInjectionPatch#3 Physician Prescribed Medication#3 Physician Prescribed Medication Dosage*#3 Physician Prescribed Medication Frequency*#3 Physician Prescribed Medication Route of Administration*MouthInjectionPatch#4 Physician Prescribed Medication#4 Physician Prescribed Medication Dosage*#4 Physician Prescribed Medication Frequency*#4 Physician Prescribed Medication Route of Administration*MouthInjectionPatch#5 Physician Prescribed Medication#5 Physician Prescribed Medication Dosage*#5 Physician Prescribed Medication Frequency*#5 Physician Prescribed Medication Route of Administration*MouthInjectionPatch#6 Physician Prescribed Medication#6 Physician Prescribed Medication Dosage*#6 Physician Prescribed Medication Frequency*#6 Physician Prescribed Medication Route of Administration*MouthInjectionPatchPatient/Guardian signatureDate Of History Form Signature* Date Format: MM slash DD slash YYYY Pain ScaleNameDescribe the character of the pain:* (i.e. numbness, tingling, burning, sharp, dull ache, other) Please indicate the RANGE of pain (least to most) that you have had over the past 24 hours by ticking the boxes in the pain scale below.* 0 (No pain) 1 2 3 4 5 6 7 8 9 10 (Severe pain) Indicate the location(s) of the pain below:* Front - Head - Left Front - Head - Right Back - Head - Left Back - Head - Right Front - Neck - Left Front - Neck - Right Back - Neck - Left Back - Neck - Right Front - Shoulder - Left Front - Shoulder - Right Back - Shoulder - Left Back - Shoulder - Right Front - Upper chest - Left Front - Upper chest - Right Back - Upper back - Left Back - Upper back - Right Front - Abdomen - Left Front - Abdomen - Right Back - Lower back - Left Back - Lower back - Right Front - Hips - Left Front - Hips - Right Back - Hips - Left Back - Hips - Right Front - Elbow - Left Front - Elbow - Right Back - Elbow - Left Back - Elbow - Right Front - Thighs - Left Front - Thighs - Right Back - Thighs - Left Back - Thighs - Right Front - Knee - Left Front - Knee - Right Back - Knee - Left Back - Knee - Right Front - Calf - Left Front - Calf - Right Back - Calf - Left Back - Calf - Right Front - Ankle - Left Front - Ankle - Right Back - Ankle - Left Back - Ankle - Right Front - Foot - Left Front - Foot - Right Back - Foot - Left Back - Foot - Right Front - Hand - Left Front - Hand - Right Back - Hand - Left Back - Hand - Right Attendance/Cancellation Policy We are honored to have the opportunity to work with you. To maximize the value of your care it is important that you commit to attending your prescribed sessions. We also know that your time is important to you. We want to maximize the benefit to you while respecting your time obligations. In order to help keep appointments readily available, and running smoothly we have implemented the following policies. Please completely read the policy before signing. For the first office visit, please arrive 15-20 minutes early. New Patient forms must be completed prior to seeing the Physical Therapist. If able, completing the forms prior to your appointment is helpful. The forms are available on our website. If you are unable to make your appointment, please call at least 24 hours in advance to cancel the appointment. Failure to do so will result in a $25 “No Show” fee for any Physical Therapy/BRIO visit. Any time that you will be late for an appointment, please call to inform us. We will always try to accommodate as we all run late sometimes. However, if you are running more than 15 minutes late, you may be asked to reschedule the appointment. Again, Baudry Therapy Center appreciates your business and is committed to timely effective sessions. If you have any questions regarding this policy, or any other matters of your care, please speak with our office staff. Patient’s NameSignature Financial Policy For Our Clinic The information below explains the financial policies of Baudry Therapy Center. We check your insurance coverage and benefits for therapy as a COURTESY to our patients. It is the patient’s responsibility to verify coverage and understand their particular insurance policy. Therapy services are billed on time-based procedure codes. Your therapist will provide care specific to your needs and will choose the appropriate charge code based on the procedures performed. At the time of your first visit, we will provide you with an ESTIMATE of the amount of money that you will need to pay based on the information we have received from your insurance. This estimate does not guarantee payment by your insurance. The amount not covered by the primary insurance will be ESTIMATED and explained to you on your first visit. This amount is payable on the date that services are rendered. When you have not met your deductible, we will request a DEPOSIT from you that is applied towards your deductible. You will receive a bill for the remainder of the insurance allowable once the claim has been filed. Insurance companies have their own schedule of what they consider to be “usual and customary.” These fees often vary between plans. Our charges are based on the time and the type of procedures used by your therapist for each session. If we are in network with your insurance, you will be responsible for the amount “allowed” by your insurance for each procedure based on your insurance contract. It is impossible for us to know the details of each individual policy. Your insurance is an agreement between you, your employer and the insurance carrier. We encourage you to contact your insurance company to better understand your benefit for therapy services. If you have had a recent procedure that should apply to your deductible, it may not have been billed by the hospital or physician’s office yet and therefore may not be listed when we checked your benefits. Please contact your insurance if you feel that your deductible information is incorrect. If you have a co-insurance percentage that you are expected to pay, we will collect an estimated amount on that co-insurance and you will receive a bill for the difference between what you paid and what the insurance company allows after we file your claim. In instances of repeated cancellations without 24 hours-notice or no-show to a scheduled appointment, we reserve the right to charge you a $25 fee as allowed by insurance contracts. In instances of repeated non-compliance with your scheduled visits, we also reserve the right to discontinue care and will inform your physician of the fact that your service has been discontinued due to non-compliance with the prescribed rehabilitation program. Patient's Date of Birth* Date Format: MM slash DD slash YYYY Patient’s Initials*Date Date Format: MM slash DD slash YYYY The undersigned certifies that he/she has read the foregoing and is the patient, the patient’s legal representative, or is duly authorized by the patient as the patient’s general agent to execute this document and accept and agree to its terms.Patient/Guardian Signature*Date Date Format: MM slash DD slash YYYY Patient Full Name*Your Information. Your Rights. Our Responsibilities. Your Information. Your Rights. Our Responsibilities. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Your Rights You have the right to: Get a copy of your paper or electronic medical record Correct your paper or electronic medical record Request confidential communication Ask us to limit the information we share Get a list of those with whom we’ve shared your information Get a copy of this privacy notice Choose someone to act for you File a complaint if you believe your privacy rights have been violated Your Choices You have some choices in the way that we use and share information as we: Tell family and friends about your condition Provide disaster relief Market our services Our Uses and Disclosures We may use and share your information as we: Treat you Run our organization Bill for your services Help with public health and safety issues Do research Comply with the law Address workers’ compensation, law enforcement, and other government requests Respond to lawsuits and legal actions Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get an electronic or paper copy of your medical record You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests. Ask us to limit what we use or share You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated You can complain if you feel we have violated your rights by contacting us using the information on page 1. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint. Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: Share information with your family, close friends, or others involved in your care Share information in a disaster relief situation In these cases we never share your information unless you give us written permission: Marketing purposes Sale of your information Most sharing of psychotherapy notes In the case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you We can use your health information and share it with other professionals who are treating you. Example: A therapist treating you for an injury asks a doctor treating you about your overall health condition. Run our organization We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services. Bill for your services We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services. How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues We can share health information about you for certain situations such as: Preventing disease Helping with product recalls Reporting adverse reactions to medications Reporting suspected abuse, neglect, or domestic violence Preventing or reducing a serious threat to anyone’s health or safety Do research We can use or share your information for health research. Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you: For workers’ compensation claims For law enforcement purposes or with a law enforcement official With health oversight agencies for activities authorized by law For special government functions such as military, national security, and presidential protective services Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. Changes to the Terms of this Notice Baudry Therapy Center This Notice is Effective as of April 1, 2018 Baudry Therapy Center Privacy Officer Leslie Baudry 2620 Metairie Lawn Dr. Metairie, LA 70002 504-841-0150 [email protected] We NEVER market or sell private information Please note on our Consent Form if you would like this notice in an alternative format.