Patient Intake Form — Exercise Based Rehabilitation from Physical Therapy

Save time and fill out your intake form before your appointment! Please fill out the form below. Items marked with an asterisk are required when submitting.

1. Patient Information

Date*

Last Name*

First Name*

Home Address*

City*

State*

Zip*

Date of Birth*

Gender
MaleFemale

Marital Status
MS

Cell Phone*

Home Phone

Work Phone

E-mail Address*

Emergency Contact Name and Phone #*

How would you like to be contacted?
Home Cell Work E-mail

Primary Care Physician*

2. Informed Consent to Evaluate / Treat

By signing below, I hereby grant permission for and request to be evaluated and treated by (including but not limited to) a physical therapist, occupational therapist, kinesiotherapist and/or other qualified therapy providers in accordance with a plan of care developed by the therapist(s) and prescribed by my physician in consultation with the therapist(s).

I understand that the purpose of this program is to enhance my recovery from an illness, injury or surgery. It has been explained to me that changes may be made to my treatment program as my condition changes. I hereby give my permission for any modifications or changes to the treatment plan that are deemed necessary by the therapist(s).

The procedures and/or treatment modalities to be used have been explained to me, and I have had the opportunity to ask any questions. I acknowledge that I have received satisfactory answers to all of my questions. I understand that the success of this or any other medical treatment program depends on my active participation and cooperation, including regular attendance at all treatment sessions and diligent follow-through with any home exercises or procedures prescribed by the therapist(s).

I understand what is expected of me as a patient and agree to cooperate to the best of my ability.

I hereby attest that I have read and agree to all of the statements above and that my participation in this therapy treatment is voluntary.

Signature of Patient or Legal Representative:
Hold down left-click on your mouse and drag the cursor over the white box to draw your signature.

Date*

3. Authorization to Disclose Health Information

This authorization includes your physician, your spouse (if applicable) and your insurance company.

1. Authorization
I authorize the use and/or disclosure of the above-named individual's protected health information as described below. The following individual(s) or organization(s) are authorized to make this disclosure.

2. Information to Be Used or Disclosed
The type and amount of health information to be used or disclosed includes (check all that apply and include dates when appropriate):
Evaluation(s)
Progress Notes
Most recent history and physical
Most recent discharge summary
Entire medical record
Other
Other (Including disclosure to my spouse, child, sibling, friend or any other(s) named here to receive information regarding my medical records.):

3. Sensitive Information
I understand that my health record may contain information related to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information related to behavioral or mental health services, and treatment for alcohol and/or substance use disorders.

4. Recipient of Information
This information may be disclosed to and used by the following individual(s) or organization(s):
Name(s):

Address:

5. Right to Revoke
I understand that I have the right to revoke this authorization at any time by submitting a written request to the Healthcare Management Office. I understand that any revocation will not apply to information already disclosed in response to this authorization. I further understand that revocation does not apply to my insurance company when the law provides the insurer with the right to contest a claim under my policy.
Unless otherwise revoked, this authorization will expire on the following date, event, or condition:

If no expiration is specified, this authorization will expire twelve (12) months from the date of signature.

6. Voluntary Authorization
I understand that authorizing the disclosure of my health information is voluntary. I may refuse to sign this authorization and understand that I am not required to sign this form in order to receive treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided under 45 CFR §164.524.
I understand that once the information is disclosed, it may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.

Signature of Patient or Legal Representative:
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Date*

4. Billing Agreement

Therapy sessions are scheduled by appointment, based on patient convenience and therapist availability. Sessions are provided in 50-minute increments.

Refund Policy
Refunds will be issued only in written consent to and from Just Be Fit, Inc. and only under the following circumstances:

The patient permanently relocates to another city or location outside Cook, Lake, or Du Page counties.
The patient's medical condition changes such that continuation of therapy is no longer medically appropriate. In such cases, written notification from a physician is required.

Unused sessions remaining one (1) year from the date of purchase will not be honored or refunded.

Exercise Based Rehabilitation Packages

# OF SESSIONS	PRICE PER SESSION	TOTAL COST
1	$125.00	$125.00
5	$115.00	$575.00
10	$105.00	$1,050.00
15	$95.00	$1,425.00

I authorize continued payment to be charged to my credit card once my package has been fully used.
YesNo

I authorize Just Be Fit, Inc. to charge my credit card for modalities or services not included in my Exercise-Based Rehabilitation package.
YesNo

If you answered "Yes" to either authorization above, please provide your credit card information below or present your card to the front desk for secure processing.

Credit Card Number

Exp Date

Security Code

I have read, understand, and agree to the policies outlined above as they relate to my participation in the Exercise-Based Rehabilitation (cash-pay) program.

Signature of Patient or Legal Representative:
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Date*

5. Cancellation / Missed Appointment Policy

A minimum of 24 hours' notice is required to cancel or reschedule a therapy appointment. Appointments canceled with less than 24 hours' notice, or missed appointments ("no-shows"), will be charged the full session fee, which may be deducted from the patient's Exercise-Based Rehabilitation package or billed directly to the patient. Patients who miss three (3) consecutive scheduled appointments without proper notice may be discharged from the Exercise-Based Rehabilitation Program.

This policy will be enforced after the patient's initial therapy appointment.

I agree to pay the fees outlined in this policy.

Initials:*

Workers' Compensation Disclosure

Just Be Fit, Inc. does not accept Workers' Compensation cases.

Please indicate whether your condition is related to work-related injury or occupational exposure:
YesNo

I understand that Just Be Fit, Inc. does not accept Workers' Compensation cases. If my condition is work-related and I fail to disclose this information, I acknowledge that I am solely responsible for payment of all services rendered and that payment is required at the time of service. I understand that I will be responsible for providing any Workers' Compensation or employer-related documentation and for handling all matters directly with any third party. Just Be Fit, Inc. is not responsible for communicating with, billing, or seeking payment from Workers' Compensation carriers, employers, or any other third party. All services are provided on a cash-pay basis, and third-party payment will not be accepted under any circumstances.

Patient Acknowledgment

I certify that the information provided above is accurate and complete to the best of my knowledge. I understand that this information will be used solely for the purpose of planning and providing physical therapy services, in accordance with applicable federal and Illinois state laws, including HIPAA.

Signature:
Hold down left-click on your mouse and drag the cursor over the white box to draw your signature.

Date*

Practice Statement

Thank you for choosing Just Be Fit, Inc. We appreciate your cooperation and look forward to providing therapy services tailored to your needs.

If you have any questions regarding our services, policies, or procedures, please ask a member of our staff.

Sincerely,
Just Be Fit, Inc. Management