160 North 8Th Street Baton Rouge, LA. 70802 (225) 383-5021 Fax (225) 383-5023

DOWNTOWN PHYSICAL REHABILITATION 160 North 8th Street • Baton Rouge, LA. 70802 • (225) 383-5021 • Fax (225) 383-5023 Geoff LeJeune, PT Clinical Director [email protected] PATIENT INFORMATION

FIRST NAME: ______TODAY’S DATE: ____/____/___ LAST NAME: ______BIRTH DATE: ____/____/____ ADDRESS: ______PATIENT’S SSN: ____/____/____ CITY ______STATE ______ZIP ______PATIENT SEX: M F HOME PHONE #: ( )______CELL PHONE #: ( ) ______EMAIL ADDRESS: ______MARITAL STATUS: SINGLE ______MARRIED ______OTHER ______HOW DID YOU FIRST LEARN ABOUT DOWNTOWN PHYSICAL THERAPY & INDUSTRIAL CENTER? ______

EMPLOYMENT STATUS: EMPLOYED _____ F/T STUDENT _____ P/T STUDENT _____ OTHER_____ OCCUPATION: ______EMPLOYMENT RELATED ACCIDENT: Y N DATE INJURED: _____/_____/_____ AUTOMOBILE RELATED ACCIDENT: Y N EMPLOYER NAME: ______PHONE #: ( ) ______ADDRESS: ______CITY ______STATE ______ZIP ______

PRIMARY CARE PHYSICIAN: ______REFERRING PHYSICIAN: ______IN CASE OF EMERGENCY: ______PHONE #: ( ) ______

PRIMARY INSURANCE: ______INSURED’S NAME: ______ADDRESS: ______INSURED’S DOB: ______/______/______CITY______STATE _____ ZIP ______INSURED’S SSN: ______/______/______PHONE #: ( ) ______RELATION TO INSURED: ______INSURED ID #: ______GROUP #: ______

SECONDARY INSURANCE: ______INSURED’S NAME: ______ADDRESS: ______INSURED’S DOB: ______/______/______CITY ______STATE _____ ZIP ______INSURED’S SSN: ______/______/______PHONE #: ( ) ______RELATION TO INSURED: ______INSURED ID #: ______GROUP #: ______

I HEREBY CERTIFY THAT ALL INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE, AND I AM RESPONSIBLE FOR ALL CHARGES INCURRED FOR THESE SERVICES. I HEREBY AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS MY

CONVENIENCE, QUALITY, AND EXPERIENCE DOWNTOWN PHYSICAL REHABILITATION 160 North 8th Street • Baton Rouge, LA. 70802 • (225) 383-5021 • Fax (225) 383-5023 Geoff LeJeune, PT Clinical Director [email protected] CLAIM AND AUTHORIZE MY INSURANCE COMPANY TO PAY DOWNTOWN PHYSICAL THERAPY & INDUSTRIAL CENTER DIRECTLY FOR SERVICES RENDERED.

PATIENT’S SIGNATURE: ______DATE: ______

CONVENIENCE, QUALITY, AND EXPERIENCE DOWNTOWN PHYSICAL REHABILITATION 160 North 8th Street • Baton Rouge, LA. 70802 • (225) 383-5021 • Fax (225) 383-5023 Geoff LeJeune, PT Clinical Director [email protected] Medical History

Patient Name: ______Date: ______Referring Physician: ______Family Physician: ______How were you injured? ______Date of injury/Onset: ______State injury occurred: ______Date of Surgery: ______What body part is injured? ______Medications Anti-Inflammatories: ______Muscle Relaxers: ______Pain Medication: ______Other Medications and why: ______

Medical Conditions

YES NO YES NO High Blood Pressure ______Hernia ______Diabetes ______Weakness ______Coronary Heart Disease ______Arthritis ______Heart Attack or Surgery ______Osteoporosis ______Shortness of Breath/Chest Pain ______Pins/Metal Implants ______Pacemaker ______Joint Replacement ______Cancer or Chemotherapy/Radiation ______Neck Injury/Surgery ______Respiratory Problems ______Back Injury/Surgery ______Stroke ______Hip Injury/Surgery ______Blood Clot ______Shoulder Injury/ Seizures/Epilepsy ______Surgery ______

CONVENIENCE, QUALITY, AND EXPERIENCE DOWNTOWN PHYSICAL REHABILITATION 160 North 8th Street • Baton Rouge, LA. 70802 • (225) 383-5021 • Fax (225) 383-5023 Geoff LeJeune, PT Clinical Director [email protected] Infectious Disease ______Elbow/Hand Injury Anemia ______Surgery ______Vision or Hearing Problems ______Leg Injury/Surgery ______Dizziness or Fainting ______Knee Injury/Surgery ______Pregnant ______Ankle/Foot Injury Smoke ______Surgery ______Broken Bones – List: ______

Patient/Guardian Signature: ______Date: ______

Therapist’s Signature: ______Date: _ Our Financial Policy Thank you for choosing us as your healthcare provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our financial policy which we require you read and sign prior to any treatment. Please let us know if you have any questions or concerns. Our office staff will be happy to provide you with more information regarding payment options.

PAYMENT OPTIONS Payment of co-pays and/or any unmet deductible is due at time of service. If you have a large deductible we can work a payment plan out for you. We accept cash, checks, or most major credit cards.

REGARDING INSURANCE We do accept assignment of insurance benefits and will be happy to file claims on your behalf. The balance is your responsibility regardless of whether your insurance company pays or not. We cannot bill your insurance company unless you give us your COMPLETE AND CURRENT insurance information. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. It is your responsibility to insure they live up to the terms of that contract. If the insurance company requests information from you, it is your responsibility to send it to them. If it is not received, your claims will be denied and you will be responsible for the amount of your bill. If the insurance company has not made full payment within 120 days we will bill you the entire amount that is owed. If you prefer to file insurance claims yourself, you may pay your account in full using the above methods. We will assist you by providing all appropriate information your insurance company will require.

Please be aware that some of the services provided may not be considered necessary under the terms of your particular plan. Please be assured that our practice will provide only those services which your doctor and physical therapist determine are necessary for you.

CONVENIENCE, QUALITY, AND EXPERIENCE DOWNTOWN PHYSICAL REHABILITATION 160 North 8th Street • Baton Rouge, LA. 70802 • (225) 383-5021 • Fax (225) 383-5023 Geoff LeJeune, PT Clinical Director [email protected]

PATIENT PAYMENT GUARANTEE Our practice is committed to providing the best treatment for our patients and our charges reflect what is usual and customary for our area. Please remember that you are responsible for all charges and expenses of Downtown Physical Therapy & Industrial Center, of every kind and description, for services, facilities and any other thing supplied or furnished the patient. If the account goes to our outside collection agency, the patient agrees to pay any additional costs in obtaining the amount due. I ______, have read and understand the above financial policy and I agree to abide by this policy.

______Signature of Patient or Responsible Party Date

CONVENIENCE, QUALITY, AND EXPERIENCE DOWNTOWN PHYSICAL REHABILITATION 160 North 8th Street • Baton Rouge, LA. 70802 • (225) 383-5021 • Fax (225) 383-5023 Geoff LeJeune, PT Clinical Director [email protected] CONSENT FOR RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS I authorize Downtown Physical Therapy & Industrial Center to release information concerning my treatment, including the reproduction of my medical records, for each third party insurer from whom I may seek payment or reimbursement for expenses related to my treatment. I further assign all benefits and authorize payments directly to Downtown Physical Therapy & Industrial Center for the insurance benefits to which I am entitled and which are otherwise payable to me, but not to exceed Downtown Physical Therapy & Industrial Center’s regular charges for services rendered during this period of treatment. I understand, unless otherwise specifically provided by contract that I am and remain financially responsible to Downtown Physical Therapy & Industrial Center until my account is paid in full, whether or not covered by this authorization.

CONSENT FOR TREATMENT

I, ______, hereby allow Downtown Physical Therapy & Industrial Center to render treatment to me based upon my specific complaints and the referral from my physician. I understand that my treatment from Downtown Physical Therapy & Industrial Center is based upon findings from my medical doctor and release Downtown Physical Therapy & Industrial Center from responsibility for resulting illness, ill effect, or reaction from treatment ordered by my physician.

I have read all of the above and certify that I understand its content. Signature of patient: ______Date: ______(Parent or Guardian if patient is under 18 years of age) (GUARDIAN IF PATIENT IS UNDER 18 YEARS OF AGE)

CONVENIENCE, QUALITY, AND EXPERIENCE DOWNTOWN PHYSICAL REHABILITATION 160 North 8th Street • Baton Rouge, LA. 70802 • (225) 383-5021 • Fax (225) 383-5023 Geoff LeJeune, PT Clinical Director [email protected] PF-1000 Notices of Privacy Practices 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.

Uses and Disclosures Treatment. Your health information may be used by staff members or disclosed to other health care professional for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members. Payments. Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated. Health care operations. Your health information may be used as necessary to support the day-to-day activities and management of Dutchtown Physical Therapy. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality. Law enforcement. Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law enforcement investigations, and to comply with government mandated reporting.

Public health reporting. Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.

Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.

Additional Uses of Information Appointment reminders. Your health information will be used by our staff to send you appointment reminder. Information about treatments. Your health information may be used to send you information on the treatment and management of your medical condition that you may

CONVENIENCE, QUALITY, AND EXPERIENCE DOWNTOWN PHYSICAL REHABILITATION 160 North 8th Street • Baton Rouge, LA. 70802 • (225) 383-5021 • Fax (225) 383-5023 Geoff LeJeune, PT Clinical Director [email protected] find to be of interest. We may also send you information describing other health-related goods and services that we believe may interest you. Fund raising. Unless you request us not to, we will use your name and address to support our fund raising efforts. If you do not want to participate in fund raising efforts, please check off the following box. □ Please do not use my information for fund raising purposes. Individual Rights You have certain rights under the federal privacy standards. These include:

 The right to request restrictions on the use and disclosure of your protected health information

 The right to receive confidential communications concerning your medical condition and treatment

 The right to inspect and copy your protected health information

 The right to amend or submit corrections to your protected health information

 The right to receive an accounting of how and to whom your protected health information has been disclosed

 The right to receive a printed copy of this notice

Dutchtown Physical Therapy Duties We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice. Right to Revise Privacy Practices As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain.

Requests to Inspect Protected Health Information

As permitted by federal regulation, we require that request to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting Scott Larson PT, OCS. Complaints

CONVENIENCE, QUALITY, AND EXPERIENCE DOWNTOWN PHYSICAL REHABILITATION 160 North 8th Street • Baton Rouge, LA. 70802 • (225) 383-5021 • Fax (225) 383-5023 Geoff LeJeune, PT Clinical Director [email protected] If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:

SCOTT LARSON DUTCHTOWN PHYSICAL THERAPY 36501 Mission Street, Ste. A PRAIRIEVILLE, LOUISIANA 70769

If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint. Contact Person The name and address of the person you can contact for further information concerning our Privacy Practices is: SCOTT LARSON DUTCHTOWN PHYSICAL THERAPY 36501 Mission Street, Ste. A PRAIRIEVILLE, LOUISIANA 70769 (225) 744-3631 Effective Date This Notice is effective on or after OCTOBER 15, 2002 SIGNATURES I have reviewed this consent form and give my permission to Dutchtown Physical Therapy to use and disclose my health information in accordance with it. ______Name of Patient (Print)

______Signature of Patient ______Date ______Signature of Patient Representative

______Relationship of Patient Representative to Patient

CONVENIENCE, QUALITY, AND EXPERIENCE DOWNTOWN PHYSICAL REHABILITATION 160 North 8th Street • Baton Rouge, LA. 70802 • (225) 383-5021 • Fax (225) 383-5023 Geoff LeJeune, PT Clinical Director [email protected]

CONVENIENCE, QUALITY, AND EXPERIENCE