Pivot Physical Therapy Patient Registration and Intake Form
This file contains the Pivot Physical Therapy Patient Registration and Intake Form. It includes sections for patient information, insurance details, medical information, and consent for treatment. Fill out this form to complete the initial evaluation process at Pivot Physical Therapy.
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How do I fill this out?
To fill out this form, start by entering your personal information and contact details. Provide your insurance information and medical history. Ensure you sign the consent and authorization sections.
How to fill out the Pivot Physical Therapy Patient Registration and Intake Form?
1
Enter your personal and contact details.
2
Fill in your insurance information.
3
Provide your medical history.
4
Sign the consent and authorization sections.
5
Submit the completed form.
Who needs the Pivot Physical Therapy Patient Registration and Intake Form?
1
Patients visiting Pivot Physical Therapy need this form to register and provide their information.
2
Legal guardians or guarantors of minor patients need this form to provide their details.
3
Referring physicians require this form to communicate patient information to Pivot Physical Therapy.
4
Insurance providers need this form to process claims and verify patient information.
5
Athletic trainers may request this form to receive the patient's plan of care.
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What are the instructions for submitting this form?
Submit the completed form to Pivot Physical Therapy by email to intake@pivotphysicaltherapy.com, by fax to (123) 456-7890, or deliver to the clinic's physical address at 123 Therapy St, Health City, ST 12345. Ensure all information is accurate to avoid any delays.
What are the important dates for this form in 2024 and 2025?
Ensure you complete and submit the form before your initial evaluation at Pivot Physical Therapy.
What is the purpose of this form?
The purpose of this form is to gather necessary patient information for the initial evaluation at Pivot Physical Therapy. It includes sections for personal details, insurance information, and medical history, ensuring accurate registration. Additionally, the form contains consent and authorization sections required for treatment and communication.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: Enter your full name including first, middle initial, and last name.
- 2. Patient Information: Provide personal details such as date of birth, gender, marital status, and contact information.
- 3. Insurance Information: Fill in your insurance details including type, policy number, group number, and subscriber information.
- 4. Medical Information: Enter your medical history, including injury details, referring physician information, and next physician visit date.
- 5. Consent to Release Information: Authorize Pivot Physical Therapy to discuss your financial account and treatment with designated individuals.
- 6. HIPAA Acknowledgement: Acknowledge receipt of the Notice of Privacy Practices.
- 7. Cancellation & No Show: Acknowledge understanding of the cancellation and no-show policy.
- 8. Financial Agreement and Assignment of Benefits: Authorize treatment, benefits application, and payment to Pivot Physical Therapy.
- 9. Direct Access Consent: Consent for direct access to physical therapy care without a referral in applicable states.
- 10. Photo & Video Release: Grant permission for photographic and video recordings for educational purposes.
What happens if I fail to submit this form?
Failing to submit this form may result in delays in receiving treatment and inability to process insurance claims.
- Treatment Delays: Your initial evaluation may be delayed if the form is not completed and submitted.
- Insurance Issues: Failure to provide insurance information may result in denied claims and out-of-pocket expenses.
How do I know when to use this form?
- 1. Initial Evaluation: Complete this form for your initial evaluation appointment.
- 2. Insurance Claims: Provide insurance details to facilitate claims processing.
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