Patient-Registration - Healing Star Physical Therapy and Wellness

Patient Demographics

Name of patient *

Date of Birth *

Gender *

Social Security Number

Marital Status *

Address *

Is this your primary residence? * YesNo

Primary Address *

Email *

Phone *

Emergency Contact

Contact Name *

Relationship to Patient *

Phone Number *

Physician Information

Please provide a Primary Care Provider, Specialist, Nurse Practitioner or Physician Assistant (Required by New Jersey State) *

Reason for Visit

Cause of Injury *

Occupation

Employer

Address of Employer

Drivers License *

Auto-insurance Declaration Page *

Letter from Auto insurance-mentioning claim number and adjuster name *

Auto insurance card

Police report

Date and Place of Accident *

Do you have an attorney representing you for this claim YesNoOther

Name of Attorney

Address of Attorney

Phone Number of Attorney

Explain what happened to cause your injury *

Date of injury *

How would you describe your injury pain? *

Where is the location of your pain (be specific)? *

What is your CURRENT rating of pain? *

What is the pain rating at its BEST? *

What is the pain rating at its WORST? *

What is the condition of your injury *

Your injury interferes with (check all that apply) WorkSleepDaily RoutineNone of the above

Explain how it interferes

Have you been treated this year for this injury by a Physical Therapist? * YesNo

How many visits this calendar year have you seen a Physical Therapist? *

Which body part have you been treated for? *

Is this injury similar to a condition in your past? *

What is your goal for physical therapy?

Health History

Medications (Please list any medications that you are currently taking, put N/A if not applicable) *

Please Scan your Medication list if Available :

Surgical Histories (list of surgeries you have had) *

Please list anything that you may be allergic to

List previous surgeries/treatments with dates

List any past serious accidents with dates

Family Health History

Do you take Supplements or Vitamins?*

Do you exercise? *

Are you on a special diet? *

Do you smoke? *

Are you wearing (check all that apply)Heel liftsSole liftsInner solesArch supports

Authorization

We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and patient. OUR OFFICE FILES YOUR CLAIMS TO YOUR INSURANCE CARRIER(S) AS A COURTESY TO YOU.YOU ARE RESPONSIBLE FOR FOLLOW-UP COMMUNICATION WITH YOUR INSURANCE COMPANY SHOULD THERE BE A PROBLEM IN PROCESSING A CLAIM.
Our policy requires payment in full for all services rendered at the time of visit. We accept cash, checks, and credit cards as payment. If your account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, and any other expenses incurred in collecting your account.
To give you the best possible service, we believe your time and our time is very valuable for treatment. WE HAVE A STRICT LATE CANCELLATION, RESCHEDULE OR NO SHOW FEE OF $75. IN ORDER TO NOT BE CHARGED, WE REQUIRE A 24-HOUR NOTICE. YOUR CARD WILL BE AUTOMATICALLY CHARGED.
I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider and or managed care organization, to release any information required to process insurance claims.

* I understand the above information and guarantee this form was completed correctly to the best of my knowledge and under-stand it is my responsibility to inform this office of any changes to the information I have provided.

General Insurance Questions

Type of Insurance? * MedicareMedicare Advantage PlansCommercialSelf Pay

Is Medicare your primary or secondary insurance? * Primary insuranceSecondary insurance

Medicare ID *

Secondary Insurance Information

Insurance Company *

Full Name of Subscriber *

DOB of policy holder *

Subscriber ID *

Medicare ID *

Primary Insurance Information

Insurance Company *

Full Name of Subscriber *

DOB of policy holder *

Subscriber ID *

Insurance Company: (AARP Medicare Complete, Aetna Medicare, Braven Medicare Advantage, Clover, Humana, UHC Dual Complete, Other)

Insurance Company * Insurance Company Name *

Full Name of Subscriber *

DOB of policy holder *

Subscriber ID *

Group Number *

Medicare ID *

Insurance Company: (Aetna, Cigna, Emblem Health, Horizon Blue Cross Blue Shield, United Health Care, United Health Care Community Plan, Oxford, Other)

Insurance Company * Insurance Company Name *

Full Name of Subscriber *

DOB of policy holder *

Subscriber ID *

Group Number *

Credit Card Holder Information

Name on Card

Billing Address

City

State

Zip

Credit Card Number

Expiration Month

Expiration Year

CVV Code

Credit Card Authorization

Please note our office files your claims to your insurance carrier(s) as a courtesy to you. Your insurance coverage is a contract between you and your insurance carrier, thus your entire account balance, including those charges filed to your insurance company, remains your RESPONSIBILITY. Your credit card will be charged for insurance co-payments at the time of service, for any balance owed after review of your final insurance payments, and for any late cancellation, reschedule or no show fees. THE AUTOMATIC CHARGE FOR EACH LATE CANCELLATION, RESCHEDULE OR NO SHOW IS $75. Any credit remaining on your account after all insurance payments have been made will be refunded to you. I further understand that this form will be attached to my permanent records and can be used for all future treatment. It will not be divulged to any person not engaged in the maintenance of said files.

I hereby authorize Healing Star Physical Therapy to charge my credit card.

Cancel and No Show Policy

The following is our policy regarding cancellations and no-shows. We take this subject seriously at our clinic because it can make the difference between whether or not your treatment is successful in a timely manner. Your referring doctor and/or therapist have prescribed a set frequency of treatment. Showing up as scheduled for these visits is your most important responsibility. Other than that, all you need to do is follow your therapist’s instructions, including your Home Exercise Program and we will be able to help you achieve your goals in treatment.

We require 24 business hours notice in the event of a cancellation or reschedule. You will be assessed a $75 charge for any appointment cancelled with less than 24 business hours notice. This fee applies to late reschedules, misses appointments and cancellations within 24 business hours of your appointment. Please initial your name below:*

This charge will NOT be covered by insurance but will have to be paid by you personally. If there is a credit card on file, it will automatically be charged for this fee. Please initial your name below:*

For patients with Worker’s Compensation, Personal Injury and No Fault insurance, documentation of any missed appointments is part of your medical record and as such can be forwarded to your Case Manager and Primary Physician. This could jeopardize your claim and you are still responsible for this charge. Please initial your name below:*

Repeated late cancels/no shows/excessive tardiness constitute non-compliance with your PT Plan of Care and make you subject to Discharge from treatment at this facility. Please initial your name below:*

When you don’t show as scheduled, three people are hurt: You, because you don’t get the treatment you need as prescribed by your MD and/or PT; the therapist who now has space in their schedule since the time was reserved for you personally; and another patient who could have been scheduled for treatment if you had given proper notice. We specialize in hands-on one-on-one quality treatment. We are out of network because we think you deserve the best. Therefore, we do not rely on volume and our schedule reflects this. Appointments are every 40 minutes so that we can take the time to work independently with each individual.

* I agree with the above policy and authorize payment for any cancellations or no shows.

Important Things to Remember

YOUR INDIVIDUALIZED TREATMENT PLAN

Our physical therapists will prescribe a treatment plan with a specific frequency and duration. You schedule according to their recommendation and you’ll be on your way to healing with the best!

COMMUNICATION

Ask questions regarding insurance, your financial obligations or your treatment plan. We are open to discussion so please call or email immediately so we can help resolve any issues.

MULTIPLE TREATMENT AREAS

We separate out cases by body part or diagnosis, especially if there are multiple complaints. Some insurance plans also limit the amount of body parts we can treat per case. This provides the best care for your condition. If you want a different body part treated, it may require a full evaluation and confirmation of insurance coverage.

24 HOUR RESCHEDULE/CANCEL/NO SHOW POLICY

Give us 24 business hours notice at minimum to change any appointment. If not, it is an automatic $75 fee to you, not your insurance.

WE RUN ON TIME

You will receive an appointment confirmation via email two days prior to each appointment. This is your reminder. Please arrive on time. If you are late, you will miss out on the 1-1 time with your therapist.

CHANGE OF CLOTHES

Please bring a change of clothes depending on your treatment area. You can leave your clothes here so that you do not need to dress for your appointment.

WORKERS COMPENSATION & NO-FAULT INSURANCE/IME’S

You must routinely see your doctor and receive an IME (Independent Medical Examination) to be authorized for further visits. If you miss your IME, you may be financially responsible for any unauthorized visits. Workers’ Compensation Patients: You must see your doctor to get a MG-2 form before your 28th visit to continue your care.

INSURANCE CHECKS

If you receive any checks from your insurance company, please bring them into our office. They are payment for our services. You are legally responsible for turning them over to your service provider. **Required for certain insurances only.

Thank you for following our policy practices to give you the Best PT in NJ!

Healing Star Physical Therapy and Wellness Online Patient Registration Form

ABOUT US

PATIENT RESOURCES

WE TREAT PATIENTS FOR

FOLLOW US