Manual Therapist HEALTH INFORMATION Patient Name ! ! ! ! ! ! ! ! ! Date ! ! ! ! Date of Injury ! ! ! ! ! SSN# ! ! ! ! Claim# !! ! ! A. Patient Information Address ! ! ! ! ! ! ! City ! ! ! ! Zip ! ! Phone: Home ! ! ! ! ! Work ! ! ! ! Cell ! ! ! ! Email Address ! ! ! ! ! ! ! ! Birthdate ! ! ! ! Employer ! ! ! ! Occupation ! ! ! Work Address ! ! ! ! Emergency Contact ! ! ! ! ! ! ! Relationship to Patient ! ! ! Phone: Home ! ! ! ! ! Work ! ! ! ! Cell ! ! ! ! Primary Health Care Provider Name ! ! ! ! ! ! ! Credentials ! ! ! Phone ! ! ! Address ! ! ! ! ! ! ! City ! ! ! ! Zip ! ! I give my massage therapist permission to consult my health care providers regarding my health and treatment. B. Current Health Information List Health Concerns (Check all that apply) Primary !! ! ! ! ! mild moderate disabling constant intermittent symptoms increase w/ activity decrease w/ activity getting worse getting better no change Treatment received ! ! ! ! ! ! ! ! ! ! ! ! Secondary ! ! ! ! ! mild moderate disabling constant intermittent symptoms increase w/ activity decrease w/ activity getting worse getting better no change Treatment received ! ! ! ! ! ! ! ! ! ! ! ! Additional ! ! ! ! ! mild moderate disabling constant intermittent symptoms increase w/ activity decrease w/ activity getting worse getting better no change Treatment received ! ! ! ! ! ! ! ! ! ! ! ! List Daily Activities Limited by Condition Work ! ! ! ! ! ! ! ! ! ! ! ! ! ! Home/Family ! ! ! ! ! ! ! ! ! ! ! ! ! Sleep/Self Care ! ! ! ! ! ! ! ! ! ! ! ! ! Social/Recreational ! ! ! ! ! ! ! ! ! ! ! ! List of Self-Care Routine How do you reduce stress?! ! ! ! ! Pain? ! ! ! ! ! ! List ALL current medications ! ! ! ! ! ! ! ! ! ! ! C. Health History List and Explain. Include dates and treatment received. Allergies ! ! ! ! ! ! ! ! ! ! ! ! ! Surgeries ! ! ! ! ! ! ! ! ! ! ! ! ! InjurIes !! ! ! ! ! ! ! ! ! ! ! ! ! Major Illnesses ! ! ! ! ! ! ! ! ! ! ! ! ! Consent for Care: It is my choice to receive manual therapy, and I give my consent to receive treatment. I have reported all health conditions that I am aware of and will inform my practitioner of any changes in my health. Contract for Care: I promise to participate as a member of my health care team. I will make sound choices regarding my treatment plan based on the information provided by my manual therapist and other members of my health care team, and my experience of those suggestions. I agree to participate in the self care program we select. I promise to inform my practitioner any time I feel my well-being is threatened or compromised. I expect my manual therapist to provide safe and effective treatment. Signature ! ! ! ! ! ! ! ! Date ! ! ! ! ! Manual Therapist INJURY INFORMATION: AUTO ACCIDENT Patient Name ! ! ! ! ! ! ! ! ! Date ! ! ! ! Date of Injury ! ! ! ! ! SSN# ! ! ! ! Claim# !! ! ! 1. Was there a police report? Yes No 2. Please describe and draw on the diagram how the accident occurred. Please indicate your car as Car-A, if you were decreasing or increasing or steady speed, head position, if the other car was moving, if your vehicle hit anything else after the initial impact, and road conditions. ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! (Please draw in this space how the accident occurred) 3. Were you aware of the approaching vehicle or did the impact catch you by surprise? Aware Surprised 4. Did you lose consciousness? Yes No 5. Where were you seated in the vehicle? ! ! ! ! ! Were you wearing a seatbelt? Yes No 6. Is the top of your headrest: Above your head Below your head Does your head touch the headrest? Yes No 7. Did any part of your body come into contact with the vehicle? Yes No Explain ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 8. Is your vehicle equipped with an airbag? Yes No Did it active? Yes No 9. Describe how you felt during and immediately after the injury: ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Later that same day ! ! ! ! ! ! ! ! ! ! ! ! The next day ! ! ! ! ! ! ! ! ! ! ! ! ! The next week !! ! ! ! ! ! ! ! ! ! ! ! The next month ! ! ! ! ! ! ! ! ! ! ! ! Describe any bruises, cuts, or abrasions as a result of the injury ! ! ! ! ! ! ! 10. Are your symptoms getting better getting worse no change What makes them feel better? ! ! ! ! ! ! ! ! ! ! ! Worse? ! ! ! ! ! ! ! ! ! ! ! ! ! 11. Which work activities are affected by the injury? ! ! ! ! ! ! ! ! ! Have your work responsibilities changed as a result of this injury? Yes No Explain ! ! ! ! What other daily activities are affected by this injury? ! ! ! ! ! ! ! ! 12. Check all of the following symptoms that you have experienced since the accident: Loss of memory Loss of balance Visual disturbances Hearing difﬁculties Difﬁculty breathing Insomnia Muscle spasm Headaches Numbness Tingling Neck Pain Upper back/shoulder pain Mid-back pain Low back pain Other ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Signature ! ! ! ! ! ! ! ! Date ! ! ! ! ! Provider BILLING INFORMATION Patient Name ! ! ! ! ! ! ! ! ! Date ! ! ! ! Date of Injury ! ! ! ! ! SSN# ! ! ! ! Claim# !! ! ! Billing Policy Our ofﬁce is set up to receive direct payment from insurance companies. For the best chance of reimbursement from your insurance carrier, we ask that you: • Contact your insurance company to determine your manual therapy coverage and provider stipulations. Coverage depends on your insurance company and the speciﬁc plan you have chosen. We have provided a list of questions for you to ask your insurance representative or attorney that will help determine your eligibility for your billing service. • You will need a current prescription for manual therapy from a primary health care provider, such as a physician or a chiropractor, in order to submit your claim. Referrals are current for 90 days unless otherwise speciﬁed. It is important that you understand your insurance policies in order for you to budget for your manual therapy services. You are personally responsible for all charges incurred in our ofﬁce. We expect payment in full until your insurance coverage has been veriﬁed. We realize that the completion of this form is an added burden to you as a consumer, and we thank you very much for your assistance. This completed form will provide both you and our billing department with important information regarding your manual therapy insurance beneﬁts and enables us to process your claim in a timely fashion. Patient Information! ! ! ! ! Insured"s Information (if other than the patient) Is the patient"s condition related to: ! ! ! ! Name ! ! ! ! ! ! ! auto collision - In what state? ! ! ! ! Address ! ! ! ! ! ! other accident !! ! ! ! ! City ! ! ! State ! ! Zip ! ! employment illness ! ! ! ! Phone: Home ! ! ! Cell ! ! ! Patient status: female male! ! ! ! Date of Birth ! ! ! ! ! ! single married/partnered other! ! ! Sex: female male Patient relationship to insured! ! ! ! Employer"s Name or School Name !! ! ! self spouse/partner child other! ! ! ! ! ! ! ! ! Insurance Information Insurance plan name or program name ! ! ! ! ! ! ! ! ! ! Member ID # ! ! ! ! ! ! ! Group # ! ! ! ! ! Customer service phone # ! ! ! ! Date & Time you called ! ! ! ! ! Name of customer service representative ! ! ! ! ! ! ! ! ! ! Insurance claim address ! ! ! ! ! ! ! City ! ! ! Zip ! ! Does the plan include a Physical Medicine and Rehabilitation beneﬁt such as Massage Therapy? Yes No Who may provide the services? Massage Therapist Physical Therapist Other Is pre-authorization required? Yes No Is a referral required? Yes No Who may refer? MD DC ND PT OD Other ! ! ! ! ! ! ! How often does the referral need to be updated to ensure continuous coverage? !! ! ! ! ! Is there a Preferred Provider list for Manual Therapists? Yes No Is Lyn Yancha / Anna Marie Mazzone / Robert Winbauer on the list? Yes No 1 Provider BILLING INFORMATION If this is a Worker!s Compensation or Labor & Industries Claim, please ﬁll out the following information: Who is the attending HCP? ! ! ! ! ! ! ! Phone ! ! ! ! Date eligibility began ! ! Number of visits authorized ! ! Number of visits remaining ! ! Dates of coverage ! ! ! ! ! Date claim closed ! ! ! ! ! If this is a Personal Injury Claim (auto accident), please ﬁll out the following information: PIP policy amount ! ! ! Dates of coverage ! ! ! PIP Available ! ! ! MedPay amount !! ! ! Dates of coverage ! ! ! MedPay Available ! ! Liability amount ! ! ! ! Dates of coverage ! ! ! Liability Available ! ! Has PIP application been received? Yes No Has attorney been consulted? Yes No Retained? Yes No Name of ﬁrm ! ! ! ! ! ! ! ! ! ! ! ! ! Address ! ! ! ! ! ! ! City ! ! ! Zip ! ! ! Phone ! ! ! ! ! ! ! Fax ! ! ! ! ! ! ! If this is a Private Health Insurance Claim, please ﬁll out the following information: (Or if your Personal Injury claim defaults to secondary coverage, please ﬁll this out) Maximum allowable beneﬁt for Physical Medicine/Rehabilitation/Manual Therapy !! ! ! ! ! In-network: Total $ ! ! # visits !! ! Remaining $ ! ! # visits left ! ! Deductible $ ! ! ! ! Satisﬁed to date $ ! ! ! Co-pay $ ! ! ! Out-of-network: Total $ ! ! # visits !! ! Remaining $ ! ! # visits left ! ! Deductible $ ! ! ! ! Satisﬁed to date $ ! ! ! Co-insurance $ ! ! ! Are these limits just for manual therapy? Yes No If no, what other types of treatment do they include? ! ! ! ! ! ! ! ! ! (i.e. physical therapy, occupational therapy, chiropractic, etc) Assignment of Beneﬁts: My signature below authorizes and direct payment of medical benefits for services billed to my health care provider: Century Massage & Bodywork, Inc. Release of Medical Records: My signature below authorizes the release of my medical records including intake forms, chart notes, reports, and billing statements to my attorneys, health care providers, and insurance case managers, for the purpose of processing my claims. (I will inform my practitioner immediately upon signing any exclusive Release of Medical Records with attorney) Financial Responsibility: It is my responsibility to pay for all services provided. In the event that my insurance company denies payment or makes a partial payment, I agree to be and remain responsible for the balance. It is also my understanding and agreement that if Century Massage & Bodywork contracted with my insurance company at a discounted rate and the agreed-upon fee has been satisfied, the balance owed on those specific visits will be waived. Signature Date 2 Receipt of Notice of Privacy Practices & Financial and Payment Policies I, _______________________________, have received a copy of Century Massage & Bodywork, Inc. (CMB)’s Notice of Privacy Practices and Financial and Payment Policies. I understand that CMB is committed to serving their customers with professionalism and caring, being sure that at all times to protect my privacy and surety of all of my Protected Health Information. Client’s Signature ________________________________ Date ___________________________________________ NOTICE 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. INTRODUCTION Century Massage & Bodywork, Inc. (CMB) understands that your medical information is private and confidential. Further, we are required by law to maintain the privacy of “protected health information” (PHI). PHI includes any individually identifiable information that we obtain from you or others that relates to your past, present or future physical or mental health, the health care you have received, or payment for your health care. As required by law, this notice provides you with information about your rights and our legal duties and privacy practices with respect to the privacy of PHI. This notice also discusses the uses and disclosures we will make of your PHI. We must comply with the provisions of this notice as currently in effect, although we reserve the right to change the terms of this notice from time to time and to make the revised notice effective for all PHI we maintain. You can always request a written copy of our most current privacy notice from the CMB’s Privacy Officer. PERMITTED USES AND DISCLOSURES We can use or disclose your PHI for purposes of treatment, payment and health care operations. For each of these categories of uses and disclosures, we have provided a description and an example below. However, not every particular use or disclosure in every category will be listed. • Treatment means the provision, coordination or management of your health care, including consultations between health care providers regarding your care and referrals for health care from one health care provider to another. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to contact a physical therapist to create the exercise regimen appropriate to your care. • Payment means the activities we undertake to obtain reimbursement for the health care provided to you, including billing, collections, claims management, determinations of eligibility and coverage and utilization review activities. For example, prior to providing health care services, we may need to provide information to your Third Party Payor about your medical condition to determine whether the proposed course of treatment will be covered. When we subsequently bill the Third Party Payor for the services rendered to you, we can provide the Third Party Payor with information regarding your care if necessary to obtain payment. Federal or State law may require us to obtain a written release from you prior to disclosing certain specially PHI for payment purposes, and we will ask you to sign a release when necessary under applicable law. • Health care operations means the support functions of our practice related to treatment and payment, such as quality assurance activities, case management, receiving and responding to patient comments and complaints, physician reviews, compliance programs, audits, business planning, development, management and administrative activities. For example, we may use your PHI to evaluate the performance of our staff when caring for you. We may also combine PHI about many patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. In addition, we may remove information that identifies you from your patient information so that others can use the de-identified information to study health care and health care delivery without learning who you are. OTHER USES AND DISCLOSURES OF PROTECTED PHI In addition to using and disclosing your information for treatment, payment and health care operations, we may use your PHI in the following ways: • We may contact you to provide appointment reminders for treatment or medical care. • We may contact you to tell you about or recommend possible treatment alternatives or other health- related benefits and services that may be of interest to you. • We may disclose to your family or friends or any other individual identified by you PHI directly relevant to such person’s involvement with your care or payment for your care. We may use or disclose your PHI to notify, or assist in the notification of, a family member, a personal representative, or another person responsible for your care of your location, general condition or death. If you are present or otherwise available, we will give you an opportunity to object to these disclosures, and we will not make these disclosures if you object. If you are not present or otherwise available, we will determine whether a disclosure to your family or friends is in your best interest, taking into account the circumstances and based upon our professional judgment. • When permitted by law, we may coordinate our uses and disclosures of PHI with public or private entities authorized by law or by charter to assist in disaster relief efforts. • We may contact you as part of our efforts to market our practice’s services as permitted by applicable law. • Subject to applicable law, we may make incidental uses and disclosures of PHI. Incidental uses and disclosures are by-products of otherwise permitted uses or disclosures which are limited in nature and cannot be reasonably prevented. • We will use or disclose PHI about you when required to do so by applicable law. [Note: In accordance with applicable law, we may disclose your PHI to your employer if we are retained to conduct an evaluation relating to medical surveillance of your workplace or to evaluate whether you have a work-related illness or injury. Your employer or CMB will notify you of these disclosures as required by applicable law.] SPECIAL SITUATIONS Subject to the requirements of applicable law, we will make the following uses and disclosures of your PHI: • Military and Veterans. If you are a member of the Armed Forces, we may release PHI about you as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority. • Worker’s Compensation. We may release PHI about you for programs that provide benefits for work- related injuries or illnesses. • Public Health Activities. We may disclose PHI about you for public health activities, including disclosures to prevent or control disease, injury or disability; to report child abuse or neglect; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; to notify the appropriate government authority if we believe that an adult patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if the patient agrees or when required or authorized by law. • Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if CMB is given assurances that efforts have been made by the person making the request to tell you about the request or to obtain an order protecting the information requested. • Law Enforcement. We may release PHI if asked to do so by law enforcement officials. • Serious Threats. As permitted by applicable law and standards of ethical conduct, we may use and disclose PHI if we, in good faith, believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public or is necessary for law enforcement authorities to identify or apprehend an individual. Note: HIV-related information, genetic information, alcohol and/or substance abuse records, mental health records and other special PHI may enjoy certain special confidentiality protections under applicable State and Federal law. Any disclosures of these types of records will be subject to these special protections. OTHER USES OF YOUR PHI Other uses and disclosures of PHI not covered by this notice or the laws that apply to us will be made only with your permission in a written authorization. You have the right to revoke that authorization at any time, provided that the revocation is in writing, except to the extent that we already have taken action in reliance on your authorization. YOUR RIGHTS 1. You have the right to request restrictions on our uses and disclosures of PHI for treatment, payment and health care operations. However, we are not required to agree to your request. To request a restriction, you must make your request in writing to the CMB’s Privacy Officer. 2. You have the right to reasonably request to receive confidential communications of PHI by alternative means or at alternative locations. To make such a request, you must submit your request in writing to the CMB’s Privacy Officer. 3. You have the right to inspect and copy the PHI contained in your medical and billing records and in any other Practice records used by us to make decisions about you. In order to inspect and copy your PHI, you must submit your request in writing to the CMB’s Privacy Officer. If you request a copy of your PHI, we may charge you a fee for the costs of copying and mailing your records, as well as other costs associated with your request. If we deny a request for access for any of the three reasons described above, then you have the right to have our denial reviewed in accordance with the requirements of applicable law. 4. You have the right to request an amendment to your PHI, but we may deny your request for amendment. In order to request an amendment to your PHI, you must submit your request in writing to the CMB’s Privacy Officer, along with a description of the reason for your request. 5. You have the right to receive an accounting of disclosures of PHI made by us to individuals or entities other than to you for the six years prior to your request. To request an accounting of disclosures of your PHI, you must submit your request in writing to the CMB’s Privacy Officer. Your request must state a specific time period for the accounting. The first accounting you request within a twelve (12) month period will be free. For additional accountings, we may charge you for the costs of providing the list. We will notify you of the costs involved, and you may choose to withdraw or modify your request at that time before any costs are incurred. COMPLAINTS. If you believe that your privacy rights have been violated, you should immediately contact the CMB’s Privacy Officer. We will not take action against you for filing a complaint. You also may file a complaint with the Secretary of Health and Human Services. CONTACT PERSON If you have any questions or would like further information about this notice, please contact the CMB’s Privacy Officer at 15 South Grady Way, Suite LL-19, Renton, WA 98057, 425-228-5217. This notice is effective as of May 7, 2003. Revised October 29, 2009 Century Massage & Bodywork's Policies: Financial Policy Century Massage & Bodywork, Inc (CM&B) is implementing its Financial and Payment Policies in order to be clear and consistent in its dealings in the financial matters of the business. CM&B's source of income for operating expenses is the payments received from its patients and insurance payors for services received. In order to meet our goal, the clinic(s) must remain in a sound financial position. We don't render services to collect money - but we must collect money to render services. We need the support of our clients and patients. By promptly meeting your obligations, we are better able to continue providing quality health care to the families of Western Washington. Payment Policy Payment is expected to be paid in full at the day of service at a discounted rate (See “Price List”). We are happy to accept cash, your check or a credit card (Visa or MasterCard) for payment of your session. There is a $35 charge for returned check fees. We accept Personal Injury, Workman's Compensation, and L&I claims. We honor medical health insurance, especially within the First Choice Health Network (FCHN), after verification. We will accept any other medical insurance on a case-by-case basis. You must bring your current health insurance card with you each time you come to the office. This is very important. You may not appreciate the subtle changes your employer has made in your benefit plan that will be reflected on your insurance card. Bringing your card with you each visit is important for you and for us. If your insurance plan requires you to pay a "copay" for your visit with us, you must make that payment at the time of your visit. We are happy to accept cash, your check or a credit card (Visa , MasterCard, American Express, or Discover) for payment of your copay. There is a $35 charge for returned check fees. Be aware that most plans require a copay for each member of the family, so if you bring another member of the family with you, two or more "copay" amounts will be due. Payment of the amount you owe is due within 30 days of the date of the statement or a monthly interest of 1% will be applied. If payment of your portion of the bill for which you are responsible is not made after the second statement has been sent, our office will contact you to arrange payment. We automatically send all overdue accounts promptly to our collection agency and the credit bureau is notified. CM&B will limit its acceptance of third party insurance claims. This is usually an auto accident with the legal representation in which the case awaits settlement. CM&B will require a minimum payment of $45 of the day's service(s) until an unpaid balance of $1,500 is reached. The client will be responsible for 100% of any amount after $1,500 based on current Time of Service prices (See “Price List”). Any unpaid balances between $400 and $1,000 (other than 3rd party claims) must be paid in full within four (4) month. Other Policy Considerations The previous policy specifies the desired payment arrangements. From time to time, exceptions will need to be made based on the patient's circumstances. It is our intention and goal to be respectful of the patient's financial condition. Cancellation Policy Our time together is important. We recommend that you schedule your appointment(s) in advance. We require 24-hour advance notice for cancellations or reschedules, or you will be charged for the full amount of your scheduled session. This also applies to gift certificates and pre-paid massage packages. If you must cancel or reschedule your appointment, please provide at least a 24-hour advance notice to avoid charges. Tardiness Policy We request that you arrive early for your appointment. This gives you some time to relax and ensures that you will receive your full session time, and in order for us to uphold our professional standards of being ‘on time,’ we regret that we cannot give you additional time if you arrive late for your appointment. If for any reason WE are late starting your appointment, you will receive the full scheduled time.
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