New Patient Intake – Optimum Physical Medicine

Patient Information
    ​Emergency Contact
    Accident Information
    Insurance Information
    PLEASE PROVIDE THIS OFFICE WITH A COPY OF YOUR INSURANCE CARD(S)
    Max file size: 20MB
    Max file size: 20MB
    Assignment and Release (Insured Patients) I certify that I (or my dependent) have insurance coverage with
    and I AUTHORIZE, REQUEST AND ASSIGN MY INSURANCE COMPANY TO PAY DIRECTLY TO THE PHYSICIAN/MEDICAL PRACTICE, INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the providers to release all information necessary, including the diagnosis and the records of any exam or treatment rendered to me, in order to secure the payment of benefits. I authorize the use of this signature on all insurance claims, including electronic submissions.

    IN CASE OF EMERGENCY

    OPTIMUM PHYSICAL MEDICINE AND REHABILITATION
    CONSENT AND CONDITIONS OF TREATMENT

    CONSENT FOR TREATMENT.
    I voluntarily consent to care and treatment of the Patient by Optimum Physical Medicine and Rehabilitation, (“OPM&R”) and its affiliated physicians, practitioners, and staff, including but not limited to outpatient medical, surgical, nursing, and therapeutic care; diagnostic, laboratory, and radiological tests and procedures; administration of pharmaceuticals; and such other care as deemed reasonably necessary or advisable by the attending physician, practitioner or staff member. If OPM&R personnel suffer a needle stick or are exposed to blood or body fluids, I consent to the testing of Patient for any blood-borne disease for the protection of OPM&R personnel.

    CONDITIONS FOR TREATMENT AT OPM&R.
    In consideration for the care and treatment that Patient will receive or has received at OPM&R, I agree to the following: 
    1. Patient Responsibilities. I agree to comply with the Patient Responsibilities set forth in OPM&R’s separate Notice of Policies, Patient Rights, and Patient Responsibilities.
    2. Payment. I agree that I am responsible for any co-payments, deductibles or other charges for services to Patient that are not paid by insurance, government programs, or other payers, except as prohibited by applicable law or any agreement between my insurance company and OPM&R. I agree to make such payments according to OPM&R’s regular terms of payment. Where appropriate, I agree to submit and cooperate with OPM&R in submitting claims to entities from which payment may be obtained, including any government program, insurance company, or other third parties. I understand that I will remain responsible for any amount not paid by insurance or a third party. If the Patient’s account becomes delinquent, I agree to pay interest and fees according to OPM&R’s policies, including but not limited to reasonable costs of collection, collection agency fees, attorneys fees, and court costs. I agree that any overpayments collected for Patient’s admission or treatment on this occasion may be applied directly to any delinquent account of Patient.
    3. Assignment. I hereby assign and authorize direct payment to OPM&R of any payments or other benefits to which I or the Patient may be entitled from any government program, insurance company, or other entity that is or may be liable for costs associated with Patient’s care. I agree that this assignment will not be withdrawn or voided at any time until Patient’s account is paid in full.
    4. Billing Practices. I understand and agree that any quote of charges for services rendered and/or insurance benefits available are estimates based upon the best information available at the time. OPM&R may amend such quotes and I will be responsible for charges for services actually rendered. I understand and agree that OPM&R will require payment of all accounts at the time the services are rendered unless OPM&R has expressly agreed to contrary arrangements. Where insurance is available, OPM&R will bill and allow a reasonable time for the insurance company to pay. I will be responsible for any amount not covered by insurance. Should payment not be received, the Patient and I will be billed for all charges and interest. Payment is due upon receipt of the bill.

    PERSONAL PROPERTY. I understand and agree that OPM&R does not assume any responsibility for my personal property and shall not be liable for any loss or damage to such personal property. 

    NO GUARANTEE. I understand and agree that the practice of medicine is not an exact science and that no guarantees have been made to me regarding the results of Patient’s care or treatment at OPM&R.

    PERSONS FOR WHOM OPM&R IS NOT LIABLE. I understand that OPM&R is only responsible for the acts of its employees acting within the scope and course of their duties. I understand that persons who are not employed by OPM&R may be involved in my care or treatment, including but not limited to members of the medical staff of OPM&R’s ambulatory surgery center, independent contractors, vendors, or product technicians. I understand that OPM&R is not liable for the acts or omissions of non-employees or OPM&R employees acting outside the course and scope of their duties. 

    NOTICE OF PRIVACY PRACTICES. I have been made available a copy of OPM&R’s Notice of Privacy Practices on this or a prior occasion. Copies are available online at www.optimumpmr.com , the front desk, or can be mailed to me at my request. 

    NOTICE OF PATIENT RIGHTS AND PATIENT RESPONSIBILITIES. I have been made available a copy of OPM&R’s Patient Rights, and Patient Responsibilities on this or a prior occasion. Copies are available online at www.optimumpmr.com , the front desk, or can be mailed to me at my request. 

    OWNERSHIP DISCLOSURE, Optimum Physical Medicine is owned by:
    • William N Rush, MD.
    • John E. McIntyre DC
    QUALITY CONTROL AND INFECTION CONTROL, OPMR maintains a monitoring program designed to prevent, control and investigate infections and communicable diseases as set forth by nationally recognized infection control guidelines. We do this by using quality assessment and performance improvement plans.

    I have fully read, understand, and agree to this Consent and Conditions of Treatment. I certify that I am either the Patient or the Patient’s legally authorized representative, and have authority to execute this Consent and Agreement on behalf of Patient. I have had the opportunity to ask questions concerning this Consent and Conditions of Treatment and have had my questions answered to my satisfaction.
    ​

    PAIN PATIENT INFORMATION / HISTORY FORM
    The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Optimum PMR or insurance company to release any information required to process my claims. 
    Please list current and ongoing problems in order of priority:
    Medical History
    Women Only Health History
    MENSTRUAL HISTORY
    MEN’S HISTORY (FOR MEN ONLY) 
    GI HISTORY 
    DENTAL HISTORY 
    Accident Information

    Treatment History

    Personal Habits
    ACTIVITY
    Family Health History
    IS THERE A FAMILY HISTORY OF ANY OF THE FOLLOWING CONDITION?
    READINESS ASSESSMENT
    I certify that the above questions were answered correctly. I understand that providing incorrect information can be dangerous to my health.
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB