Patient Information Sheet Patient Information Form Please complete this form before your first visit at Goldsboro Physical Therapy. Step 1 of 8 12% Name* Nickname First Email* Enter Email Confirm Email Date* MM slash DD slash YYYY Birth Date* MM slash DD slash YYYY Do you have a pacemaker?*YesNoMarital Status*SingleMarriedCurrent Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneWork PhonePreferred method of communication*Phone CallText MessageEmail Employer Work Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code If you are a student, what school? If you are a student, are you full time?YesNo Name of Spouse First Last Spouse's Employer Spouse's PhoneReferring Physician* Part of body injured/hurt* Date of onset of symptoms MM slash DD slash YYYY If applicable, date of accident MM slash DD slash YYYY Is your condition or injury work related?*YesNoIf applicable, date of Injury MM slash DD slash YYYY Is your condition or injury due to an automobile accident (MVA)?*YesNoIf applicable, date of MVA MM slash DD slash YYYY Is your condition or injury due to a school or sports related injury?*YesNoIf applicable, did your accident occur in North Carolina?YesNoWhat state did your accident occur? If you are under 18 years of age, please fill out the information on this page. If you are over 18, you may skip to the next page.Father Birth Date MM slash DD slash YYYY PhoneMother Birth Date MM slash DD slash YYYY PhoneLegal Guardian Birth Date MM slash DD slash YYYY PhoneWho will be financially responsible for the bill? INSURANCE INFORMATION: We will make copies of your card(s) for our records.Primary Insurance Policy # Policy Holder Policy Holder's Date of Birth MM slash DD slash YYYY Secondary Insurance Policy # Policy Holder's Name Policy Holder's Date of Birth MM slash DD slash YYYY I understand and agree that health and accident insurance policies are an arrangement between my insurance company and myself - not between my insurance company and Goldsboro P.T. I agree to pay my estimated copay/coinsurance at the time the services are rendered. In the event that my insurance company does not pay my charges at the estimated rate or within a reasonable period of time, upon request of this office, I will immediately pay the balance owing on my account. I authorize GPT to release any medical information relating to my treatment to any insurance companies that may be responsible for paying benefits to me, and to any attorneys who may be representing me due to my condition, and to complete any usual and customary reports and forms at no charge to assist in collecting from my insurance companies, attorneys or other payors. I have read, understand and agree to all of the above. The information that I have provided is true and complete to the best of my knowledge.I agree to the above statement.* I agree Patient's Name* Date* MM slash DD slash YYYY Guardian's Name (If patient is a minor) Date MM slash DD slash YYYY This notice describes how medical information about you may be used or disclosed and how you can get access to information. Please review it carefully. Goldsboro Physical Therapy's Legal Duty Goldsboro Physical Therapy is required by law to protect the privacy of your personal health information, provide this notice about our information practices and follow the information practices that are described herein. Uses and Disclosures of Health Information Goldsboro Physical Therapy uses your personal health information primarily for treatment; obtaining payment for treatment; conducting internal administrative activities and evaluating the quality of care that we provide. For example, Goldsboro Physical Therapy may use your personal health information to contact you to provide appointment reminders, or information about treatment alternatives or other health related benefits that could be of interest to you. Goldsboro Physical Therapy may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law. In any other situation, Goldsboro Physical Therapy's policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time. Goldsboro Physical Therapy may change it's policy at any time. When changes are made, a new Notice of Information Practices will be posted in the waiting room and patient exam areas and will be provided to you on your next visit. You may also request an updated copy of our Notice of Information Practices at any time. Patient's Individual Rights You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reason other than treatment, payment or other related administrative purposes. You may also request in writing that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances, Goldsboro Physical Therapy will consider all such requests on a case by case basic, but the practice is not legally required to accept them. Concerns and Complaints If you are concerned that Goldsboro Physical Therapy may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact our practice manager at the address listed below. You may also send a written complaint to the US Department of Health and Human Services. For further information on Goldsboro Physical Therapy's health information practices or if you have a complaint, please contact the following: Goldsboro Physical Therapy Lori Grady, Office Manager 2503 Wayne Memorial Dr. Telephone: 919-734-1311 Fax: 919-734-8816 I have read and fully understand GPT’s Notice of Information Practices. I understand that GPT may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice. I also understand that GPT will consider requests for restrictions on a case-by-case basis, but does not have to agree to requests for restrictions. I hereby consent to the use and disclosure of may personal health information for purposes as noted in GPT’s Notice of Information practices. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time. I also consent to the release and disclosure of my personal health information to Goldsboro Physical Therapy from any medical providers as deemed necessary by my physical therapist for my care and treatment consisting of doctor’s notes, lab reports, x-ray and MRI reports.I Agree to the Patient Information Consent Form* I Accept Patient Name* Date* MM slash DD slash YYYY DESIGNATED INDIVIDUALS AUTHORIZATION FORM I hereby authorize one or all of the parties below to request and receive any protected health information regarding my treatment, payment or administrative operations related to treatment and payment. I understand that the identity of designated parties must be verified before the release of any information.Name Relationship Authorized to Receive... Medical Information Billing Information Scheduling Information Name Relationship Authorized to Receive... Medical Information Billing Information Scheduling Information Name Relationship Authorized to Receive... Medical Information Billing Information Scheduling Information How would you like to deliver this form? Digitally Send to Goldsboro Physical Therapy Print and bring into the office visit Your intake forms have been emailed to you for you to print. Δ
