New Patient Form

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  • Emergency Contact Information

  • Fill out this section if the primary insured is other than yourself(i.e.spouce/parent)

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  • Guarantor (If other than patient)

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  • Please list all persons able to access patient records or updates:

  • **If you are a returning patient and None of your above information has changed, please sign

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  • Have you EVER been diagnosed as having any of the following: (Check yes or no)

  • Have you experienced any of the following in the last 90 days? If so, please explain:

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  • Please list any prescription medication that you are currently taking (including pills, injections, over the counter medication herbal supplements, and /or skin patches) **If you are unsure a substance is a medication, please list it for consideration. If you have a list of your medication already prepared please allow us to make a copy for our records and you may leave the medication section blank Thank you.

  • Allergies (of suspected Allergies)

  • Injury History Information

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  • CANCELLATION/NO SHOW FEE

    Premier Physical Therapy takes great pride in providing all of our patients with exceptional one on care by our Doctors of Physical Therapy. This time is set aside for you and only you. To guarantee or patients the opportunity to be seen in timely manner and to be fair to all patients in scheduling, we require 48 hours working business day notice to cancel a scheduled appointment. If you do not cancel within 48 hours of your schedules appointment time, a $45 cancellation fee will be changed to your account. This cannot be billed to insurance. Please consider that the quality of your care and the amount of improvement you will make depends greatly on your consistency with the appointments you make. (Initial)

    By not giving this proper notice, Premier Physical Therapy has my advanced permission to charge my credit card on file any fees associated with missed of cancelled appointment not cancelled within 48 hours notice agreement. If not credit card is on file, I agree to pay this fee at my next scheduled visit or Premier Physical Therapy may bill me any missed visits. I also understand all outstanding missed/no show feed must be paid in-full before any new appointment can be made.
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  • CONSENT TO TREAT

    For and in consideration of the medical treatment, which I many receive while a patient of Premier Physical Therapy & Sports Performance (here after Premier), I either severally or collectively consent to treatment, voluntarily and knowingly, by me if of age and competent of for me, if a minor or incompetent, by my parents, guardian or nearest relative, as the case may be, to the said members of Premier separately or collectively, to carry out, or cause to be carried out such medical treatment, as prescribed or ordered by my physician.

    AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFITS

    Ihereby authorize Premier, or any holder of medical information about me to release to the Health Care Funding Administration and its agents (Medicare) or Insurance Companies or Third Parties, any information need to determine these benefits or the benefits payable for related services. I request that authorized Medicare or Insurance payments be made to Premier (to be used only if necessary to file claims.)

    AGREEMENT AND RELEASE OF LIABILITY

    Ido hereby waive Premier and all employees, and the owner of any responsibility from any injury due to the use of equipment/machinery or any other accident occurring within the facility. I hereby agree to accept responsibility for any and all risks of injury.

    PRIVANCY NOTICE

    By my signature below, I acknowledge that I have received a copy of the HIPPA Privacy Act “Notice of Information Practices,” and understand my rights as a patient regarding my personal health information.

    INSURANCE PROTOCOL

    Medicare: Upon receipt of payment and/or denial form Medicare, your secondary insurance will be billed as a courtesy, one time only per date of treatment. If there is a remaining balance after all insurance companies have been billed you will be responsible for this balance which will be provided for you in the form of a statement. Commercial/Group: Before your initial evaluation our office will verify your benefits. You will be expected to pay your co-pay or coinsurance at the beginning of each vis

    GUARANTOR RESPONSIBILITY

    I understand that I am ultimately responsible for payment of any and all charges for medical services rendered by Premier and if this assignment is rejected, modified or not paid within a reasonable time after it has been filed, it will be my responsibility to pay any unpaid charges in full. If it is necessary to collect unpaid fees for services rendered, I agree to pay the charge assessed by the collection service, legal counselor court. I may revoke this authorization and assignment at any time by written notice. I agree that a copy of this form may be used in lieu of the original.
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