Patient Registration Form
Today's Date: |
Patient Name:
(first, middle, last) | |
| Street Address: | | City: | |
| State: | | Zip: | |
| Home Phone: | | | |
| Work Phone: | | | |
| Cell Phone: | | | |
| Social Security #: | | | |
Date of Birth:
mm/dd/yyyy) | | | |
| Email Address: | | | |
| If patient is a minor, name of parent/guardian: |
| Relationship: |
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| Employer: |
| Employer Name: | |
| Street Address: | | City: | |
| State: | | Zip: | |
| Phone: | | | |
| Physician(s): If your physician is not in the local area, please fill in address and phone information (Unless you have prescription/referral with you that contains this information.) |
| Referring Physician Name: |
| Phone: |
| Address: |
| Primary Care Physician Name: |
| Phone: |
| Address: |
| Health Insurance Information: Please provide us with your card |
| Primary Ins. Co.: | | Subscriber: | | Patient Relationship to Subscriber: Self Spouse
Dependent Other | | Subscriber D.O.B: | | Subscriber Employer/Group: | | | | | | | Secondary Ins. Co.: | | Subscriber: | | Patient Relationship to Subscriber: Self Spouse
Dependent Other | | Subscriber D.O.B: | | Subscriber Employer/Group: | | | | 1. Have you had physical therapy in the past year? Yes No | | If Yes,When? Where? | | Diagnosis treated: | | 2. Have you had any home care services in the past year? Yes No | | If Yes,When? Agency? | | 3. Have you been a patient of Ramsey Rehab in the past? Yes No | | If Yes,When? | | | | Assignment & Instruction for Direct Payment to Health Provider | Insurance company name(s):
| I hereby instruct the above named insurance company (ies) to pay by check made out to and mailed directly to: Ramsey Rehabilitation, Inc.
39 Cinema Boulevard
Leominster, MA 01453 For medical and professional expenses allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above mentioned assignee and I have agreed to pay, in a current manner, any balance of said professional fees for non-covered services and/or fees, over and above the insurance payment or as required by my invariance policy. I also agree to pay interest on any balance past 90 days. I understand that Ramsey Rehab complies with HIPAA and will protect my Personal Health Information (PHI) and will use it as allowable by law in the treatment, billing and collections pertaining to my care. HIPAA Policy is available to me in the waiting room binder and upon request. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney for the purpose of securing payment under this policy of insurance or to any medical provider associated with my case to effectively treat me. This authorization is in effect until 90 days from the date the last bill is collected. A photocopy of this Assignment shall be considered effective and valid as the original.
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| Patient Signature*: | | Date: | |
| * I am aware that submitting my full name on this online form IS my electronic signature for consent. |
| Optional: Please restrict access to my personal health information (PHI) from: |
| Name: | |
| Address: | |
| Phone: | |
Consent to Treatment
I hereby authorize the staff of Ramsey Rehabilitation, Inc. to examine and treat me with physical therapy procedures and modalities necessary for the injury/diagnosis for which I have presented here. |
| Patient Signature*: | | Date: | |
| * I am aware that submitting my full name on this online form IS my electronic signature for consent. |
