OFFICE IN SCREENING
Have you traveled to an affected area within the last 14 days?
Have you had close contact with a confirmed COVID patient?
Do you have any of the following?
In case of an emergency who should be notified?
Have you received care from another Healthcare Professional for this injury?
Where is your problem? (Please circle all that apply for this visit)
Did you have surgery for this condition?
Which is your Dominant Arm?
Functional Limitations: (Please circle all that apply)
Home Layout: (please check all that apply)
Please indicate nature of your symptoms (Please circle only one)
How did you injure yourself?
Is there a Workers Comp Claim?
Are you currently working?
Patient Initial Intake Form
How severe is the pain (0=none, 10=severe pain)
Have you had similar symptoms in the past?
In general would you say your health right now is
Are you currently pregnant, or trying to become pregnant?
Do you have Latex Allergies?
Medical History: (please check all that apply)
Please list your medications, dose and frequency (please include any vitamins or over the counter medications)
ASSIGNMENT OF BENEFITS As a medical provider, our relationship is with you, not your insurance company. As a courtesy to our patients, we are willing to submit your claims to your insurance company for reimbursement, providing your insurance company allows us to do so. However, all charges are ultimately your responsibility from the first date services are rendered. To this regard, you are responsible for your co-payments, deductible and any portion of your claims your insurance company chooses to exclude from payment. If you have any questions regarding the above or any uncertainty regarding your insurance coverage, please do not hesitate to ask us. We are here to assist you.
PRIMARY INSURANCE INFORMATION
SECONDARY INSURANCE INFORMATION
ASSIGNMENT OF BENEFITS
Provider: William J. Schwarz, P.T., P.C.
5700 Merrick Road
Massapequa, NY 11758
In consideration of services rendered, I hereby assign to the provider and or his/her assignees so much of my first-party insurance benefits and rights shall equal the full amount of the bill for such services and the provider and his/her assignees may secure in my name. If the above provider is an in-network provider of my primary insurance then my financial liability is limited to that which these insurance companies require to pay (i.e. co-payments, deductibles coinsurance, etc). Also by signing this form I understand that I authorize this office to release all information regarding my condition for payment purposes of my claims if my insurance company requires such. This authorization will be void once all claims are paid in full.
I HEREBY STATE THAT THE INJURY WHICH I AM RECEIVING TREATMENT FOR IS NOT DUE TO A WORKMAN’S COMPENSATION CASE OR NO FAULT ACCIDENT.
IT IS THE PATIENTS RESPONSIBILITY TO INFORM US IF YOUR INSURANCE CARRIER CHANGES DURING YOUR TREATMENT HERE.
IF YOU FAIL TO INFORM US YOU WILL BE HELD RESPONSIBLE FOR ALL CHARGES NOT COVERED.
Any employee found violating this policy will be reprimanded up to and/or including termination of employment. Violation of a patient’s privacy if found guilty will be subject to civil liability and/or criminal penalties. We are required to report any employee found violating this policy to the Department of Civil Rights. Penalties are as follows: Civil Federal criminal penalties are $100 per violation, up to $25,000 per person per year each requirement of prohibition violated. Federal criminal penalties are up to $50,000 and one year in prison for obtaining protected health information; up to $100,000 and up to five years in prison for obtaining or disclosing protected health information under “false pretenses”; and up to $250,000 and up to 10 years in prison for obtaining or disclosing protected health information with intent to sell, transfer or use it for commercial advantage, personal gain and malicious harm.
II. Patient Charts
Staff members such as PT Aides, front desk staff and Therapists all have access to patient charts for the following reasons; to treat the patient, to set up for a patients treatment plan, request authorization, as well as follow up on claims for payment due at our office, filling out paperwork; maintaining & securing records and communication with the insurance companies and governmental agencies. This will be done on a discrete manner with as little incidental disclosure as possible. A patient or their qualified representative has the right to inspect their patient information within 30 days of our office receiving a written request with the patient’s original signature or qualified representative’s original signature. Copies of the patients chart maybe furnished to the patient at a charge of $75/per page. A patient’s chart may not be copied or reviewed by third party without written authorization from the patient or a qualified representative. This request may be written within 30 days of the patient’s/representative’s dated signature. Copies will not be released with a Photostat copy of the patient’s/representative’s signature unless the authorization states otherwise. A patient or their qualified representative may challenge the accuracy of their information and may require their own brief statement be inserted as a permanent part of their patient information and released whenever the information is released. This individual’s right only pertains to factual statements and not to a provider’s observations, inferences or conclusions. You have the right to receive an accounting of disclosures of protected health information. Patients have the right to make restriction or transfers of their protected health information at any time.
III. Insurance Companies
A patients progress notes will only be released to an insurance company when it is necessary to prove medical necessity for additional visits and or payment of claims. When this information is released to such companies only the necessary information will be released. Information that does not support the medical necessity for continued treatment will not be released. This will be determined by the treating providers own discretion. No Fault cases require copies of patient’s progress notes with each claim. When this information is released to such companies only the necessary information will be released. (Workman’s Compensation cases are excluded from the HIPAA privacy policies.)
The US Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue
Washington, D.C. 20201
William J. Schwarz, P.T., P.C.
5700 Merrick Road
Massapequa, NY 11758
HIPAA Release of Information
MEDIA RELEASE AUTHORIZATION FORM
I hereby authorize The Schwarz Institute of Physical Therapy and Pro Sports Care of L.I., and its duly authorized employees or agents, to publish the following personal health information / story: (e.g., information relating to the diagnosis, treatment, and health care services provided or to be provided to me and which identifies my name and other personally identifiable information) to be used in print media, on the radio, TV, the OSC website, blog and on the following social media platforms: Facebook, Twitter, Pinterest, and You Tube.
The following information about me will not be disclosed:
I understand that any personal health information or other information released via the social media platform(s) above may be subject to re-disclosure by such social media platform(s) and may no longer be protected by applicable Federal and State privacy laws.
This authorization is valid from the date of my/my representative's signature. I understand that I have a right to revoke this authorization by providing written notice to the Schwarz Institute of Physical Therapy and Pro Sports Care of L.I.
However, this authorization may not be revoked if The Schwarz Institute of Physical Therapy and Pro Sports Care of L.I., its employees or agents have taken action on this authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my eligibility for benefits or enrollment or payment for or coverage of services.