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☎ (315) 569-9308
✉ homestretchpt@gmail.com
Home
About
Our Therapists
Services
Testimonials
How to Start Care
Insurance
Service Area
Contact
FAQ
Careers
☎ (315) 569-9308
✉ homestretchpt@gmail.com
New Patient History Form
New Patient History Form
Patient Information
Title
Mr.
Ms.
Mrs.
Miss.
Dr.
Name
*
First Name
Last Name
Social Security #
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Billing Address (if different)
Date of Birth
*
Gender
Male
Female
Email
*
Phone 1
Home
(###)
###
####
Phone 2
Cell
(###)
###
####
Phone 3
Office
(###)
###
####
Referring Physician
*
Referring Physician Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Type of Injury
*
Date of Injury
*
MM
DD
YYYY
Occupation
*
If Still Working
Have you ever had any other treatment for this condition?
*
When is your next doctor's appointment scheduled?
*
Have you received physical therapy, occupational therapy, or chiropractic services in the past year?
*
Yes
No
Have you had home health care prior to physical therapy?
*
Yes
No
May messages be left on your home phone?
*
Yes
No
How did you hear about Home Stretch Physical Therapy ?
*
Insurance Information (please include all insurances)
Primary Insurance
*
ID#
*
Insurance Policy Holder
*
DOB
*
MM
DD
YYYY
Secondary Insurance
ID#
Insurance Policy Holder
DOB
MM
DD
YYYY
Patient's Name Printed
*
Patient/Guardian Signature
*
Date
*
MM
DD
YYYY
Designated Individuals Authorization
I hereby authorize the designated party(s) below to request and receive any of my protected health information regarding treatment, payment, or administrative operations. I understand that the identity of these designated parties will be verified before the release of any information
*
First Name
Last Name
Relationship
*
Phone #
*
(###)
###
####
Name
First Name
Last Name
Relationship
Phone #
(###)
###
####
Past Medical History
Do you now, or have you ever had any of the following conditions (check all that apply)
Diabetes
High Blood Pressure
Pacemaker
Kidney Problems
Allergies to Heat
Metal Implants
Breathing Difficulties
Rheumatoid Arthritis
Hearing Loss
Migraine Headaches
Heart Disease
Heart Attack
Heart Murmur
Nervous Disorders
Allergies to Ice
Pregnant (currently)
Muscular Dystrophy
Multiple Sclerosis
Poor Eyesight
Dizziness
Seizures
Cancer
Hernia
HIV Positive
Epilepsy
Gout
Fainting
Polio
Other
Please list any medications you are currently taking including dosage
Relevant Surgical History
Patients Name Printed
*
First Name
Last Name
Patient/Guardian Signature
*
First Name
Last Name
Date
*
MM
DD
YYYY
General Consent for Service, Release of Information & Financial Authorization
I. I voluntarily consent to the evaluation and treatment of my condition by a NYS licensed Physical / Occupational (circle applicable provider) Therapist . The therapist will explain the nature and purposes of these procedures, evaluation, and course of treatment. The therapist will inform me of expected benefits and complications, and any discomforts, and risk that may arise, as well as alternatives to the proposed treatment and the risk and consequences of no treatment. II. I understand that as a courtesy to me, Home Stretch Phyiscal Therapy will bill my insurance carrier and make every reasonable effort to assist in expediting insurance payment. I, the patient, am responsible for all charges not paid by insurance. I understand that I am ultimately responsible in making sure my insurance company releases payment directly to Home Stretch Physical Therapy. Any payment sent to me will be forwarded to Home Stretch Physical Therapy. NOTICE OF ADVICE: treatment may not be covered by your specific health care plan or insurer without a referral. Co-insurances and Co-pays will be paid at time of visit or billed to patient or authorized designee. III. I understand that Home Stretch Physical Therapy reserves the right to charge $50.00 "cancellation fee" of scheduled appointments with less than 24 hours notice. It will be MY sole responsibility to pay for these charges. Home Stretch Physical Therapy also reserves the right to discharge any patient, for any reason, including canceling of scheduled appointments. If my account has an outstanding balance over 30 days, it will be charged an additional $10.00 per month finance charge. IV. I authorize the release of medical information necessary to process claims to insurance companies or their agencies (including Medicare) for the purpose of filing and payment of medical claims. I authorize payment of medical benefits to the provider. V. I understand and agree that if it becomes necessary for Home Stretch Physical Therapy to commence any legal action or to obtain an attorney for collection of any outstanding balances on my account, I will be responsible for all reasonable fees incurred by Home Stretch Physical Therapy, in addition to the outstanding balance due. VI. I agree to allow Home Stretch Physical Therapy to obtain any necessary medical history that will benefit my treatment outcome. I have read the above certifications, or they have been read to me and I fully understand them.
Patient's Name Printed
*
First Name
Last Name
Patient/Guardian Signature
*
First Name
Last Name
Date
*
MM
DD
YYYY
Thank you!
