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Home  Cell  Work |  |  |  |  |  | Check if we may leave messages?  Home  Cell  Work |  |  |  |  |  |\n| Employer: |  |  | Employer Address: |  |  |  |  |  |  |  |  |\n| Email: |  |  |  |  |  |  |  |  |  |  |  |\n| Height (in inches): Weight (in lbs): |  |  |  |  |  |  |  |  |  |  |  |\n\nInsurance Information-Please include ALL insurance coverage  \n\n| Insurance / Payment Method:  GROUP/PRIVATE INURANCE  VA  SELF PAY  MEDICARE  AUTO  WORKMANS COMP  MEDICAID |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| Name of Insurance Company: PRIMARY | ID / Policy \\#: |  | Group \\# | Insurance Phone \\# |\n| Policy holder’s Name: |  | Policy holder’s SS\\# |  | Policy holder’s DOB: / / |\n| Policy holder’s Relationship to patient: |  | Policy holder’s employer: |  |  |\n| Name of Insurance Company: SECONDARY | ID / Policy \\#: |  | Group \\# | Insurance Phone \\# |\n| Policy holder’s Name: |  | Policy holder’s SS\\# |  | Policy holder’s DOB: / / |\n| Policy holder’s Relationship to patient: |  | Policy holder’s employer: |  |  |\n\nWorkman’s Comp/Auto Insurance Information  \n\n| Insurance Name |  | Claim \\# |  | Date of Injury / / |\n| --- | --- | --- | --- | --- |\n| Adjustor Name |  | Phone ( ) - |  | Ext. |\n| Is there an attorney involved?  Yes  No | If yes, Attorney’s Name: |  | Attorney’s Phone ( ) - |  |\n\nEmergency Contact Information  \n\n| In case of an Emergency please contact: |  |  |\n| --- | --- | --- |\n| Relationship | Phone ( ) - | May we speak to them about your care?\u003Cbr> Yes  No |\n\nReferral Information  \n\n| Referred By: | PCP, if different: |\n| --- | --- |\n| Referring Physician: | Referring Physician Company: |\n\nPlease turn page over to continue .  \nTotal Function Physical Therapy, PC ©2019  \nNew Patient Information  \nWelcome to Total Function Physical Therapy, PC!  \nWe would like to thank you for choosing Total Function Physical Therapy, PC. We want to assure that your experience with us will be a pleasant one. Here is some of what you can expect on your first visit:  \n􀁸 Please arrive at least 30 min early on your first visit so that we may obtain copies of necessary insurance information, and you will be required to fill out a Patient History Form regarding your symptoms.  \n􀁸 Please dress appropriately for your physical therapy sessions. We require that you wear comfortable clothing and footwear when you come to your appointments. Any type of loose clothing is suitable. Sweatshirts, sweatpants, shorts, and t-shirts usually work well. Dresses, skirts, jeans and any tight clothing are not recommended.  \n􀁸 It is ok if you are on medication for your symptoms; continue your medication as prescribed by your physician.  \n􀁸 Expect to spend approximately one hour at our clinic for your first visit. After that, your appointments will be approximately 45 minutes in duration; treatment time includes therapist’s documentation time.  \n􀁸 If you have any special needs, questions, or concerns about your initial visit, please do not hesitate to contact us and we will be more than happy to assist you.  \n􀁸 We are required by law to maintain the privacy of your health information and to make available to you this description of our privacy practices. We will abide by the terms of this notice and will notify you if we cannot agree to a specific restriction that you may have requested. We will accommodate reasonable requests you may have to communicate health information by alternative means or alternative location  \n􀁸 Your first visit will include an Initial Evaluation by your ","cbCaigqDWpZpf2nA","https://ap.wps.com/l/cbCaigqDWpZpf2nA","pdf",755083,9,"English","# Patient Intake Form\n## Patient Information\n## Insurance Information\n## Workman’s Comp/Auto Insurance Information\n## Emergency Contact Information\n## Referral Information\n# New Patient Information\n# HIPAA Release Form","[{\"question\":\"What does the HIPAA release form authorize?\",\"answer\":\"The HIPAA release authorizes specific persons and facilities to request and receive protected health information. It also lists the types of records that may be disclosed and explains that re-disclosure may no longer be protected under federal privacy regulations.\"}]","Patient Intake Form - New Patient Information - HIPAA Release Form | PDF",1789854462]