New Patient Form

Please Sign after reading the statements:

1. Consent to Treatment: I consent to rehabilitation and related services at Catalyst Orthopedic & Sports Physical Therapy, LLC. In so doing, I understand, acknowledge, and affirm that such rehabilitation and related services may involve bodily contact, touching, and/or direct contact of a sensitive nature.

2. Treatment of Minor: I, as a parent/guardian of a minor receiving treatment hereunder, do hereby agree and understand that I have been advised to remain on the premises during any such treatment, and waive any claim I may have resulting from failure to do so.

3. Liability: I know and agree that Catalyst Orthopedic & Sports Physical Therapy, LLC is not responsible for loss or damage to personal valuables.

4. Authorization of Payment: I hereby assign all benefits directly to Catalyst Orthopedic & Sports Physical Therapy, LLC, and authorize the release of any medical records necessary to facilitate my treatment to process medical claims and as otherwise permitted or required in the Notice of Privacy Practices. I understand fully that in the event my insurance company or financially responsible party does not pay for the services I received, I will be financially responsible for payment.

*

Medical History Questionnaire

The purpose of this questionnaire is to help us understand your health status. Please complete this form and your therapist will answer any questions during your exam. This form is considered part of your medical report.

Patient Responsibility and Policy Form

Private Insurance Patients: 1. Co-Payments are due at the time of service (each session). 2. Patients should schedule follow-up appointments every 30 days with their Physician. 3. There will be a $35 fee for any cancellation made less than 24 hours prior to your appointment time. 4. The treating therapist has the discretion not to treat patients that are more than 15 minutes late for their scheduled appointment. 5. Patients are encouraged to schedule appointments 2-3 weeks in advance. (We cannot guarantee your regularly scheduled appointment times.) 6. Authorization may be required. 7. It is the patient’s responsibility to now his/her insurance plan. If a referral is needed the patient should have it upon their appointment time. Workers Compensation & Automobile Accident Patients: 1. Patients should schedule follow-up appointments every 30 days with their Physician. 2. There will be a $35 fee for any cancellation made less than 24 hours prior to your appointment time. 3. The treating therapist has the discretion not to treat any patients that are more than 15 minutes late for their scheduled appointment. 4. Patients are encouraged to schedule appointments 2-3 weeks in advance. (We cannot guarantee your regularly scheduled appointment times.) 5. It is recommended that you obtain an attorney to help assist you in your case (Recommendations can be provided at your request).

Patient Consent for Use and Disclosure of Protected Health Information

I hereby give consent for Catalyst Orthopedic & Sports Physical Therapy, LLC to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by Catalyst Orthopedic & Sports Physical Therapy, LLC describes such uses and disclosures more completely.) I have the right to review the Notice of Privacy Practices prior to signing this consent. Catalyst Orthopedic & Sports Physical Therapy, LLC reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to: Jason A. Nunn, DPT, CSCS 9309 Snowden River Parkway, Suite D Columbia, MD 21046 (410) 884-9080 With this consent, Catalyst Orthopedic & Sports Physical Therapy, LLC may call my home or other alternative location and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others. With this consent, Catalyst Orthopedic & Sports Physical Therapy, LLC may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.” With this consent, Catalyst Orthopedic & Sports Physical Therapy, LLC may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Catalyst Orthopedic & Sports Physical Therapy, LLC restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

Acknowledgement of Privacy Practices

The Notice of Privacy Practices was offered to me and I have been provided an opportunity to review it. I am aware that I am entitled to a copy of this Notice and that I have the opportunity to review it at any time, upon my request.
*
Powered by