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Personal Information
Patient Intake Form I
Patient Intake Form II
Patient Intake Form III

Personal Information

Personal Information

  • Emergency Contact

  • Employer Information

  • Responsible Party Information

 

Patient Intake Form I

Injury: Medical History

  • Please show us where it hurts?

  • Past Medical History

  • FEMALES ONLY

  • Please legibly list all of the prescription Medications that you are currently taking:

  • Work Environment

  • Home Environment

  • Activities

  • 0= unable to perform at all
    10= able to perform with no pain or limitations at all
 

Patient Intake Form II

Notice of Privacy Practices

  • THIS NOTICE DESCRIBES HOW PROTECTED MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.

    1) This practice is permitted to make uses and disclosures of protected health information for treatment, Payment and health care operations, as described in the following examples:
    a) For treatment - consultation, lab work, pharmacy, x-ray, etc.
    b) For payment - claim filing, collection payment due, etc.
    c) For health care operations - chart maintenance, regulatory requirements, accounting, HIPAA compliance activities, etc.

    2) This practice is permitted or required, under specific circumstances, to use or disclose protected health information without the individual’s written authorization. Other uses and disclosures will be made only with the individual’s written authorization, and the individual may revoke such authorization.

    3) This practice may engage in the following activities: a) this practice may contact the individual or other immediate adult family members to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to the individual or patient.

    4) The individual has the following rights regarding protected health information:
    a) the right to request restrictions on certain uses and disclosures of protected health information. This practice is not required to agree to a requested restriction, however.
    b) the right to receive confidential communications of protected health information, as applicable.
    c) the right to inspect and copy protected health information, as provided in the Privacy Regulation
    d) the right to amend protected health information, as provided in the Privacy Regulation.
    e) the right to receive an accounting of disclosures of protected health information.
    f) the right to obtain a paper copy of the Notice from the covered entity upon request. This right extends to an individual who has agreed to receive the Notice electronically.

    This practice is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and Privacy practices with respect to protected health information. This practice is required to abide by the terms of the Notice currently in effect. This practice reserves the right to change the terms of this Notice. The new Notice provisions will be effective for all protected health information that it maintains. The practice will provide individuals or patients with a revised Notice as requested. Individuals may complain to this practice, and to the Secretary of the Department of Health and Human Services, without fear of retaliation by the organization, if they believe their privacy rights have been violated. Complaints may be submitted in writing to Apex physical rehabilitation 4610 Sweetwater Blvd Suite 120 Sugarland Texas 77479. This Practice’s Contact for matters relating to complaints is: Dr. Amir Kazemi PT, DPT @ 281 242 5252 or you may contact: OFFICE FOR CIVIL RIGHTS (OCR) @ (214) 767-4056 FAX (214) 767-8940, US DEPT OF HEALTH & HUMAN SERVICES, 1301 YOUNG ST., STE 1169 , DALLAS , TX 75202. This notice is first in effect on April 14, 2003. This practice can elect to limit the uses or disclosure that it is permitted to make by law.
 

Clinic and Attendance Policy

  • Welcome! We would like to take this opportunity to welcome you to Apex Physical Rehab & Wellness and to thank you for choosing our organization for your physical rehab & Wellness needs. We are constantly striving to make our offices more efficient and to provide the best possible service to you. In an effort to do so we ask that you help us with the following:

    • In order to receive the maximum benefit from your rehabilitation program, it is of utmost importance that you attend all of your therapy appointments and follow the home exercise instructions. Appointments are given on the hour (Ex: 0900 am, 1000am, 1100am etc.).Patients who are more than 15 minutes late may have to wait until the next available time slot. If you will be late or need to change your appointment please contact the front desk of the facility that has you scheduled; be aware that changes are subject to availability. Treatment time is limited to a maximum of 1 hour, in most cases, from the time you are brought back to the treatment area. Please respect the next patient’s/therapist’s appointment time and depart at completion of treatment. Refrain from using cell phones/recording devices during treatment.
    • We request that you notify us if you are unable to keep your appointment. In such case please notify the receptionist 24 hours prior to you scheduled appointment. Failure to attend an appointment will result in a $75.00 fee. You may reschedule any scheduled appointment time on the same date, subject to availability, without a penalty. Failure to attend 3 scheduled sessions, without prior notice, can result in release from our care with notification sent to you and your physician. In addition patients, covered by workers’ compensation, that fail to attend appointments will have their claims adjuster and treating physician notified and may have their case sent for review or denial.
    • It is your responsibility to schedule your appointments at least one week in advance; in fact we encourage you to schedule your entire treatment in advance if you can.
    • Your appointments can be on any day of the week just not 3 days in a row.
    Please do not ask any of the staff about the conditions of other patients being treated as it violates ethical and privacy standards.
    • Please advise the receptionist of other physician appointments to avoid a schedule conflict. If scheduling due to work is a concern we can provide your employer with a note specifying the days and the times that you will be attending therapy.
    • We require you to wear the appropriate attire for treatment. T-shirts sweat shirts, shorts, sweatpants and tennis shoes are preferred. Open toe sandals and high heels are not allowed. • Any person accompanying the patient will need to wait in the designated waiting area for the sake of safety and privacy. Only patients will be allowed in the treatment area. Another adult must accompany children under the age of 10.
    Your insurance will be billed unless other arrangements have been made. You may receive monthly statements/bills. If you have any billing questions or need Medical records please contact 281 573-1766. The clinical staff /receptionist do not have the authority or information to answer billing/statement or financial questions. Please allow 72 hours for processing of medical records.
    • Exceptions to the above policy are considered on a case-by-case basis. If you have any questions or feel that you have a special situation that requires special consideration: please contact the front office as soon as possible
 

Patient Intake Form III

Patient Intake Form

 

Personal Injury

    Injury/Accident Information

  • Auto Information

  • I consent to treatment as necessary or desirable to the care of the patient first named above, including but not restricted to whatever form of physical rehabilitation, functional abilities evaluation, or other diagnostic studies that may be used by the attending therapist, or his or her qualified designate. I have been informed of potential risks and benefits of treatment. I acknowledge full responsibility for the payment of such services and agree to pay them in full at the time of service, unless other arrangements are made with the financial department. I understand that insurance coverage is an arrangement between the insurance carrier and the patient. APEX Physical Rehabilitation & wellness will assist in billing my insurance company, but I am ultimately responsible for payment should my insurance fail to pay within a reasonable period of time. I Authorize APEX Physical Rehabilitation & Wellness to release information required as to my insurance or third party payor (including my employer’s workmen’s’ comp carrier, if applicable), for purpose of determining benefits. I understand that such records may include information regarding HIV/AIDS testing, substance abuse, and/or mental health issues. I also authorize APEX Physical Rehabilitation & wellness to bill my insurance or third party payor, and receive payment directly from them for services rendered. This authorization shall remain valid for a period of 2 years, or until such time as I revoke it in writing. A photo copy or faxed copy of this authorization shall be deemed as valid as the original. I also understand that my failure to attend 3 scheduled sessions, without prior notification, can result in my release from the care of Apex Physical Rehabilitation and wellness. In addition I also understand that each failure to attend will result in a cancellation of fee of $75.00 unless a 24 hour cancellation notice is provided by me.
  • ASSIGNMENT OF BENEFITS AND DESIGNATION OF AUTHORIZED REPRESENTATIVE

 

Medicare/ Medicaid

    Primary Insurance Information

  • Secondary Insurance Information

  • I consent to treatment as necessary or desirable to the care of the patient first named above, including but not restricted to whatever form of physical rehabilitation, functional abilities evaluation, or other diagnostic studies that may be used by the attending therapist, or his or her qualified designate. I have been informed of potential risks and benefits of treatment. I acknowledge full responsibility for the payment of such services and agree to pay them in full at the time of service, unless other arrangements are made with the financial department. I understand that insurance coverage is an arrangement between the insurance carrier and the patient. APEX Physical Rehabilitation & wellness will assist in billing my insurance company, but I am ultimately responsible for payment should my insurance fail to pay within a reasonable period of time. I Authorize APEX Physical Rehabilitation & Wellness to release information required as to my insurance or third party payor (including my employer’s workmen’s’ comp carrier, if applicable), for purpose of determining benefits. I understand that such records may include information regarding HIV/AIDS testing, substance abuse, and/or mental health issues. I also authorize APEX Physical Rehabilitation & wellness to bill my insurance or third party payor, and receive payment directly from them for services rendered. This authorization shall remain valid for a period of 2 years, or until such time as I revoke it in writing. A photo copy or faxed copy of this authorization shall be deemed as valid as the original. I also understand that my failure to attend 3 scheduled sessions, without prior notification, can result in my release from the care of Apex Physical Rehabilitation and wellness. In addition I also understand that each failure to attend will result in a cancellation of fee of $75.00 unless a 24 hour cancellation notice is provided by me.
  • Home Health Episode/Previous Treatment

 

Private Insurance

    Primary Insurance Information

  • Secondary Insurance Information

  • I consent to treatment as necessary or desirable to the care of the patient first named above, including but not restricted to whatever form of physical rehabilitation, functional abilities evaluation, or other diagnostic studies that may be used by the attending therapist, or his or her qualified designate. I have been informed of potential risks and benefits of treatment. I acknowledge full responsibility for the payment of such services and agree to pay them in full at the time of service, unless other arrangements are made with the financial department. I understand that insurance coverage is an arrangement between the insurance carrier and the patient. APEX Physical Rehabilitation & wellness will assist in billing my insurance company, but I am ultimately responsible for payment should my insurance fail to pay within a reasonable period of time. I Authorize APEX Physical Rehabilitation & Wellness to release information required as to my insurance or third party payor (including my employer’s workmen’s’ comp carrier, if applicable), for purpose of determining benefits. I understand that such records may include information regarding HIV/AIDS testing, substance abuse, and/or mental health issues. I also authorize APEX Physical Rehabilitation & wellness to bill my insurance or third party payor, and receive payment directly from them for services rendered. This authorization shall remain valid for a period of 2 years, or until such time as I revoke it in writing. A photo copy or faxed copy of this authorization shall be deemed as valid as the original. I also understand that my failure to attend 3 scheduled sessions, without prior notification, can result in my release from the care of Apex Physical Rehabilitation and wellness. In addition I also understand that each failure to attend will result in a cancellation of fee of $75.00 unless a 24 hour cancellation notice is provided by me.
 

Workers Compensation

    Injury/Accident Information

  • W/C Insurance Information

  • I consent to treatment as necessary or desirable to the care of the patient first named above, including but not restricted to whatever form of physical rehabilitation, functional abilities evaluation, or other diagnostic studies that may be used by the attending therapist, or his or her qualified designate. I have been informed of potential risks and benefits of treatment. I acknowledge full responsibility for the payment of such services and agree to pay them in full at the time of service, unless other arrangements are made with the financial department. I understand that insurance coverage is an arrangement between the insurance carrier and the patient. APEX Physical Rehabilitation & wellness will assist in billing my insurance company, but I am ultimately responsible for payment should my insurance fail to pay within a reasonable period of time. I Authorize APEX Physical Rehabilitation & Wellness to release information required as to my insurance or third party payor (including my employer’s workman’s’ comp carrier, if applicable), for purpose of determining benefits. I understand that such records may include information regarding HIV/AIDS testing, substance abuse, and/or mental health issues. I also authorize APEX Physical Rehabilitation & wellness to bill my insurance or third party payor, and receive payment directly from them for services rendered. This authorization shall remain valid for a period of 2 years, or until such time as I revoke it in writing. A photo copy, or faxed copy of this authorization shall be deemed as valid as the original. I also understand that my failure to attend 3 scheduled sessions, without prior notification, can result in my release from the care of Apex Physical Rehabilitation and wellness. In addition I also understand that each failure to attend will result in a cancellation of fee of $75.00 unless a 24 hour cancellation notice is provided by me.
  • JOB PHYSICAL DEMANDS

  • Please answer the following questions

  • 3.) IN YOUR OWN BEST ESTIMATE, How much TOTAL TIME do/did you spend:
 
 
 

APEX PHYSICAL THERAPY AND FITNESS

  • Functional Testing (Consent and Release From)

 
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