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?
Patient Name PATIENT INFORMATION
First Name *
Last Name *
For Appt. Confirmation: Email *
Cell Phone *
If Patient is a Minor; Parent Guardian Name
Who may we thank you for referring you to our office? EMERGENCY INFORMATION
In case of an emergency who should be notified?
Physician referring you for Physical Therapy
Have you received care from another Healthcare Professional for this injury?
If yes, Please list name/phone
Where is your problem? (Please circle all that apply for this visit)
Did you have surgery for this condition?
Type of Surgery?
Which is your Dominant Arm?
Do you smoke? (If yes, how much?)
Have you had prior Hospitalization? (If yes please explain)
Do you have a history of falls? (If yes please explain)
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?
How long have you had symptoms?
Date of Injury
Briefly describe your injury
Are you currently working?
Name of Occupation
How long? (Out of work since)
Previous treatments for this injury (medications, injections, bracing, surgery, Chiropractic, pain management)
Date Patient Initial Intake Form
Patient Name How severe is the pain (0=none, 10=severe pain)
What makes your problem better?
What makes your problem worse?
Have you had similar symptoms in the past?
If yes, Date and Treatments you received
Previous Surgeries (include dates)
In general would you say your health right now is
Are you currently pregnant, or trying to become pregnant?
Do you have Latex Allergies?
Do you have any Allergies?
Medical History: (please check all that apply)
Please list your medications, dose and frequency (please include any vitamins or over the counter medications)
Frequency ABOUT YOUR MEDICARE BENEFITS
The following are some facts you should be aware of regarding your Medicare Benefits for Physical Therapy:
1. This office is a participating provider of Medicare.
2. Medicare requires their beneficiaries to satisfy $206.00 yearly deductible before they will begin paying. 3. After your deductible is satisfied, Medicare will reimburse 80% of what they consider to be an "approved fee" providing they do not exceed the charges. An exclusion is a charge that is not covered by your Medicare Plan. Medicare states that in this case, the patient is responsible for the actual charge billed by the provider. 4. Effective 1/1/21 there is a Monetary Cap on Physical Therapy Benefits combined with Speech Therapy Benefits as well. The maximum dollar amount Medicare will allow is $2,110.00 of which they will pay 80% - ($1,688.00) and the member will be responsible for the remaining 20% - ($422.00). 5. On assigned claims, the beneficiary, who is the patient, is responsible for the co-insurance (20% of the approved charge), the deductible per calendar year and any exclusion. 6. To continue Physical Therapy past 30 days, Medicare requires that you return to your Primary Care Physician/ referring Physician within 30 days of your last dated prescription. To determine medical necessity for continued care WE WILL NEED AN UPDATED PRESCRIPTION EVERY 30 DAYS FROM THE PREVIOUS ONE TO ENSURE MEDICAL NECESSITY. THIS IS THE PATIENT'S RESPONSIBILITY. 7. If you are receiving any HOME CARE SERVICES from an agency, Medicare will not cover any services at our facility. Medicare stipulates that any patient who is receiving home care services (i.e. Home Health Aide, visiting nurse, etc) must receive all services through that agency. Please inform the front desk staff if you are currently receiving or plan to receive any HOME CARE SERVICES. Any claims denied for this reason will be your responsibility as you have been informed prior to treatment that this is not allowed by Medicare.
If you have any additional questions about your Medicare benefits, please ask one of the front office members of your Medicare Representative.
I have read the above regarding my Medicare benefits and understand my responsibility as the beneficiary/patient.
Signature of Patient/Beneficiary MEDICARE ASSIGNMENT FORM ASSIGNMENT OF BENEFITS:
Name of Beneficiary
I request that payment of authorized Medicare benefits be made on my behalf to WILLIAM J. SCHWARZ, P.T., P.C. for any services furnished me by the said provider. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services.
SECONDARY INSURANCE INFORMATION:
Social Security # MEDICARE REGULATIONS
To continue Physical Therapy beyond 30 days, Medicare now requires that you return to your doctor within 30 days of your last dated prescription to determine medical necessity for treatment. Medicare may deny benefits for Physical Therapy if found without documented cause from your doctor. Therefore you are advised to return to your doctor within each 30-day period of Physical Therapy treatments.
****If you are receiving any HOME CARE services from an agency (i.e. Home Health Aide, visiting nurse, etc.) Medicare will not cover any services at our facility. Medicare stipulates that any patient who is receiving such services must receive all services through that agency. Please inform the front desk if you are currently receiving or plan to receive any HOME CARE services. Any claims denied for this reason will be your responsibility as you have been informed prior to treatment that this is not allowed by Medicare. If you have any questions please do not hesitate to ask any of our office staff or contact your Medicare representative.
I have read the information above regarding my Medicare benefits and understand what my responsibility is as the beneficiary/patient.
I also authorize this office to release any reports/findings to my referring physician.
I HEREBY STATE THAT THE INJURY IN WHICH I AM RECEIVING TREATMENT FOR IS NOT DUE TO A NO FAULT ACCIDENT OR WORKMAN'S COMPENSATION CASE.
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
Patient Name 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.
Name of Patient/Client
If you are human, leave this field blank.