Patient Intake Form

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

Today's Date*

Last Name*

First Name*

Home Address*

City*

State*

Zip*

Date of Birth*

Gender
MaleFemale

Marital Status
MarriedSingle

Cell Phone*

Home Phone

Work Phone

Email Address*

Emergency Contact Name*

Emergency Contact Phone Number*

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

Referring Physician*

Primary Care Physician*

Please tell us how you learned of our services or whom we can thank:

2. Insurance Information

Are You Self Paying?
YesNo

Primary Insurance Company Name

Secondary Insurance Company Name

3. Responsible Party / If Patient is a Minor

Last Name

First Name

Responsible for Payment

If yes, please provide Social Security Number:

Date of Birth

Relationship To Patient

Home Phone

Cell Phone

Email Address

Authorization and Assignment-Insurance

I authorize my insurance carrier to pay benefits directly to Just Be Fit, Inc. /MBW RCM. I agree to be financially responsible for charges not paid by insurance, including collection/legal fees if the account becomes delinquent.

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

Date

4. 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) by 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:
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Date

5. 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):

Evaluations
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

6. Cancellation / Missed & Late Arrival Appointment Policy

Please be advised that we require at least 24 hours' notice to cancel or reschedule a therapy appointment (including but not limited to, physical therapy, occupational therapy, and massage therapy).

Appointments canceled with less than 24 hours' notice or missed appointments ("no-shows") may result in a $105 cancellation fee, which is not covered by insurance and is the patient's or legal representative's responsibility.

If a credit card is kept on file, the patient authorizes Just Be Fit, Inc. to charge the cancellation fee to that card. If payment is declined, future appointments may be suspended until the balance is paid.

Repeated missed or late-canceled appointments may result in discharge from care at the discretion of the treating therapist and/or clinic management.

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

Initials:*

Late Arrival Policy:

All therapy appointments are one-on-one sessions lasting approximately 45 – 50 minutes. Patients who arrive late will receive treatment for the remaining scheduled time, as clinical safety and scheduling permit.

Initials:*

7. Financial Responsibility & Insurance Acknowledgment

Thank you for choosing Just Be Fit, Inc. for your physical, occupational, and healthcare needs. Please review the financial policy below.

FINANCIAL POLICY: Just Be Fit, Inc. contracts with many insurance plans. It is the patient's responsibility to cooperate in the verification that Just Be Fit, Inc. is in-network with their insurance provider.

Insurance Benefits:
As a courtesy, Just Be Fit, Inc. may verify insurance benefits; however, this is not a guarantee of coverage or payment. Insurance determinations may change before or after claims are processed.

Patients are responsible for: Co-payments, Deductibles, Coinsurance, Non-covered services, and Denied claims.

By initialing and signing below, I acknowledge and agree to the following:

I am financially responsible for all services rendered by Just Be Fit, Inc. including co-payments, deductibles, coinsurance, non-covered services, and late cancellation or missed appointment fees.

Insurance verification is not a guarantee of payment. I am responsible for any balance not paid by my insurance.

I am responsible for knowing my insurance benefits, referral requirements, and authorization rules. Failure to obtain required referrals or authorizations may result in denial of payment.

I agree to notify Just Be Fit, Inc. of any changes to my insurance coverage prior to my next appointment.

I authorize Just Be Fit, Inc. to bill my insurance directly for services provided.

If a credit card is kept on file, I authorize charges for patient-responsible balances in accordance with clinic policy.

Balances unpaid after 90 days may be subject to collection efforts as permitted by law.

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

Payment & Collections Policy:
Payment is due at the time of service unless other arrangements have been made. Returned or refund checks may be subject to a processing fee. Repeated non-payment may result in suspension of services, except as prohibited by law.

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

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT:
I acknowledge that I have received a copy of Just Be Fit, Inc.'s Notice of Privacy Practices, which explains how my protected health information may be used and disclosed in accordance with HIPAA.
Initials:*

CREDIT CARD AUTHORIZATION:

By signing below, I authorize Just Be Fit, Inc. to charge my credit card on file for all patient-responsible amounts, including but not limited to co-payments, coinsurance, non-covered services, late cancellation or no-show fees, and any balances not paid by insurance, in accordance with clinic policy.

I understand that insurance coverage is not a guarantee of payment and that all patients keep a valid credit card on file. I further understand that I am financially responsible for all charges not covered by my insurance plan. These may include, but are not limited to, supplies and services such as Braces (back, ankle, and knee), Coban wrap, Kinesio-taping, Electrical Stimulation (E-stim) pads, Heel pads, Arch pads, Toe pads, Iontophoresis, Dry Needling, Thera-bands or CLX bands, Golf balls, Ice packs, and similar items.

I have read and accept the policies of Just Be Fit, Inc.
I authorize Just Be Fit, Inc. to charge my credit card any outstanding balances over 90 days as well as the appropriate cancellation fee if needed.

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

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

Notice of Health Information Practices

This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Understanding Your Health Record/Information
Each time you visit a hospital, physician or other healthcare provider a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment and a plan for future care or treatment. This information often referred to as your health medical record serves as a:

Basis for planning your care and treatment
Means of communication among may health professionals who contribute to your care
Legal document describing the care you received
Means by which you or a third-party payer can verify that services billed were actually provided
A tool in educating health professionals
A source of data for medical research
A source of information for public health officials charged with improving the health of the nation
A source of data for facility planning and marketing
A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve

Understanding what is in your record and how your health information is used helps you to:

Ensure its accuracy
Better understand who, what, when and why others may access your health information
Make more informed decisions when authorizing disclosure to others

Your Health Information Rights
Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:

Request a restriction on certain uses and disclosures or your information as provided by 45 CFR 164.522
Obtain a paper copy of the notice of information practices upon request
Inspect and copy your health record as provided for in CFR 164.525
Amend your health record as provided in 45 CFR 164.528
Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528
Request communication of your health information by alternative means or at alternative locations
Revoke your authorization to use or disclose health information except to the extent that action has already been taken

Our Responsibilities
This organization is required to:

Maintain the privacy of your health information
Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
Abide by the terms of this notice
Notify you if we are unable to agree to a requested restriction
Accommodate reasonable requests you may have to communicate health information by alternative or at alternative locations

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you've supplied us.

We will not disclose your health information without your authorization, except as described in this notice.

For more information or to Report a Problem
If you have questions and would like additional information, you may contact Just Be Fit, Inc. at (847) 444-1348.

If you believe your privacy rights have been violated, you can file a complaint with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

Examples of Disclosures for Treatment, Payment and Health Operations

We will use your health information for treatment.
For example: Information obtained by your physical therapist will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of your physical therapist. Your therapist will then record the actions he/she took and their observations. In that way the physician will know how you are responding to treatment.
We will also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you're discharged from therapy.

We will use your health information for payment
For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures and supplies used.

We will use your health information for regular health operations.
For example: Members of the medical staff, the corporate compliance officer, or other members of our physical therapy staff may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

Business Associates:
There are some services provided in our organization through contacts with business associates. Examples include our billing service. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we've asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your information.

Communication with family:
Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person's involvement in your care or payment related to your care.

Research:
We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

Marketing:
We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Workers Compensation:
We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public Health:
As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Law Enforcement:
We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

Effective Date: 3-20-13