I do voluntarily consent to the treatment that has been recommended by my physician. Further, I acknowledge that no guarantees have been made to me regarding the outcome of this treatment, which I have authorized.
I understand that as part of my health and medical care, Oklahoma Physical Therapy originates and maintains medical and health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I further understand that this information serves as a basis for planning my care and treatment; a means of communication among the health professionals who contribute to my care; a source of information for applying my diagnosis and treatment information to my bill; a means for a third-party payer to verify that services were billed as actually provided; and a tool for routine healthcare operations such as assessing the quality and reviewing the competence of healthcare professionals. I further understand and agree that this agreement to release information shall apply to all information accumulated up to this date and to any information acquired in the future.
By Oklahoma law we are required to notify you…. that the information authorized for release may include records which may indicate the presence of a communicable disease which may include, but is not limited to, diseases such as hepatitis, syphilis, gonorrhea and the human immunodeficiency virus, also known as Acquired Immune Deficiency Syndrome (AIDS).
I hereby assign to Oklahoma Physical Therapy, all payments for medical all services rendered to me or my dependents. I understand that I am responsible for payment of my account(s) and that this document does not release me from that obligation. I understand that I am ultimately responsible for understanding and complying with the requirements of my insurance carrier including but not limited to co-payments, deductibles, precertification/recertifications for services provided, non-covered services/supplies, disputed worker compensation claims, etc., and will be held responsible for portions of my bill not covered by my insurance (including charges associated with canceled or missed appointments.
A 24-hour notice is required in the event of cancellation. It is the patient’s responsibility, when they call to have an alternative time in mind that will ensure they get the full prescribed number of treatments. A $25 fee for DFancellation without proper notice and $50 fee for a no-show will be imposed and will NOT be covered by insurance, including workers’ compensation and will be the sole responsibility of the patient. Co-payments, co-insurance and /or deductible payments will be due at the time of service.
I authorize any credit balance to be distributed at the discretion of Oklahoma Physical Therapay. It is the patients responsibility, when they call to have an alternative time in mind that will ensure they get the full prescribed number of treatments.
I authorize my assignment of benefits to be paid directly to Oklahoma Physical Therapy. I understand I am financially responsible to Oklahoma Physical Therapy for services not authorized and/or not covered by the insurance company. I authorize the release of any medical or other information necessary to process claims.
I understand all of the above and hereby state that the information is correct to the best of my knowledge. My signature indicates that I have read the above and grant the request of consent/authorizations.
If you have any specific questions or concerns regarding this policy, please call our business office at (405) 749-6281.
I (WE) UNDERSTAND AND ACCEPT THE TERMS OF THE ABOVE-OUTLINED FINANCIAL POLICY AND WILL ABIDE BY THE STATED TERMS.
In our continuing efforts of improve the efficiency of our financial operations, we wish to explain the management of our delinquent accounts. As the vast majority of our patients are responsible and reliable in reconciling their accounts in a timely fashion, this information may be unnecessary for the most of you. However, it is our responsibility to ensure that all our patients are aware of our financial policies. Accordingly, we ask that you read the following policy statement and indicate your understanding and acceptance of its terms by signing in the space indicated below.
You are expected to pay for services at the time they are rendered. If you have insurance, your payment portion is due at the time of service. If no payment is made on our account within thirty (30) days of the date of service, a past due statement will be mailed to the home address provided. If payment in full is not received within another thirty (30) days, your account will be placed with a law firm or collection agency for more formal collection efforts. Such a referral of our account may result in litigation if it is deemed necessary, and the individuals indicated below may be held liable for the principal, court costs and any attorney’s fees awarded if the matter is placed in judgment. Any unpaid account will be charged interest at the statutory interest rate allowed by law in the state of Oklahoma and late charges of $10.00 per month if not paid in full within sixty (60) days of the date of service.
If you have any questions or concerns regarding this policy, please call our business office at (405) 775-2866.
I (We) understand and accept the terms of the above outlined financial policy and will abide by the stated terms.
4. Since that time/injury is it: ______ same ______ getting worse ______ getting better
Yes Same
Yes Getting Worse
Yes Getting Better
5. If pain is present, describe pain (ie. constant, burning, intermittent ache)
6. Describe any previous treatments/exercises
7. Check activities that may aggravate your symptoms (any/all that apply)
Yes Standing Greater Than ___ Minutes
Yes Walking Greater Than ___ Minutes
Yes Sitting Greater Than ___ Minutes
Yes With Triggers
Yes Changing Positions
Yes Light Activity
Yes Vigorous Activity
Yes With Sexual Activity
Yes With Cough / Sneeze
Yes With Laughing / Yelling
Yes With Lifting / Bending
Yes With Cold Weather
Yes With Nervous / Anxiety
Yes No activity affects this
Yes Other
Sitting Greater Than ___ Minutes(Please fills in a 1 or 2 digit number)
Walking Greater Than ___ Minutes(Please fills in a 1 or 2 digit number)
Standing Greater Than ___ Minutes(Please fills in a 1 or 2 digit number)
If you choose YES Other, Please Describe:
8. What relieves your symptoms
9. What are your treatment goalsconcerns
Date of Last Gynecology Exam:
Tests Performed:
Activity/Exercise: ---1-2 days / week3-4 days / week5+ days / weekNone
Describe Activity Exercise
Yes Cancer
Yes Heart Problems
Yes High Blood Pressure
Yes Ankel Swelling
Yes Anemia
Yes Low Back Pain
Yes SI Joint / Tailbone Pain
Yes Osteoporosis
Yes Fibromyalgia
Yes Rheumatoid Arthritis
Yes Allergiest (list below)
Yes Hypothyroidism
Yes Headaches
Yes Irritable Bowel Syndrome
Yes Box STD
Yes Physical or Sexual Abuse
Yes Childhood Bladder Problems
Yes Depression
Yes Anorexia / Bulimia
Yes Pelvic Pain
Yes Smoking History
Yes Stroke
Yes Multiple Sclerosis
Surgical/Procedure History: Please list and describe procedures to the back/spine, brain, female organs, bladder/prostate, bones/joints, and/or abdominal organs:
(OB/GYN History): (Check Below)
Yes Child Birth Vaginal Deliveries # Yes Episiotomy # Yes C-Section # Yes Difficult Childbirth # Yes Prolapse or organ falling out Yes Vaginal dryness Yes Painful periods Yes Menopause – when? Yes Painful vaginal penetration Yes Pelvic Pain
Medications
Bowel/Bladder Habits: (Check-Belows)
Yes Trouble initiating stream Yes Urinary intermittent/slow stream Yes Trouble emptying bladder completely Yes Difficulty stopping the urine stream Yes Dribbling after urination Yes Constant urine leakage Yes Blood in the urine Yes Painful urination Yes Trouble feeling bladder urge/fullness Yes Current laxative use Yes Trouble feeling bowel urge/fullness Yes Constipation/Straining Yes Trouble holding back gas/feces Yes Recurrent bladder infection
1. Frequency of urination: awake hours = ___ times per day
1. Sleep Hours = ___ times per night
2. The usual amount of urine passed is: _______ small _______ medium _______ large
Yes Small
Yes Medium
Yes Large
3. Frequency of bowel movements times per day times per week Or Describe
4. Average fluid intake for the day? (include water and other drinks)
5. Describe the feeling if you have “falling out” feeling of your organs/prolapse/or pelvic heaviness. Specify whether it is occasionally, with prolonged standing, activity, etc.)
6. If you are having incontinence/leakage, how many times a day or week do you leak, or is it only with physical exertion/cough?
7. If you have leakage, how much do you leak on average? (ie. a few drops, wets underwear, wets outerwear, etc.)
I acknowledge and understand that I have been referred for evaluation and treatment of pelvic floor dysfunction. Pelvic floor dysfunctions include, but are not limited to, urinary or fecal incontinence; difficulty with bowel, bladder, or sexual functions; painful scars after childbirth or surgery; persistent sacroiliac or low back pain; or pelvic pain conditions.
I understand that to evaluate my condition it may be necessary, initially and periodically, to have my therapist perform an internal pelvic floor muscle examination. This examination is performed by observing and/or palpating the perineal region including the vagina and/or rectum. This evaluation will assess skin condition, reflexes, muscle tone, length, strength and endurance, scar mobility, and function of the pelvic floor region. Such evaluation may include vaginal or rectal sensors for muscle biofeedback.
Treatment may include, but not be limited to, the following: observation, palpation, use of vaginal weights, vaginal or rectal sensors for biofeedback and/or electrical stimulation, ultrasound, heat, cold, stretching and strengthening exercises, soft tissue and/or joint mobilization, and educational instruction.
I understand that in order for therapy to be effective, I must come as scheduled unless there are unusual circumstances that prevent me from attending therapy. I agree to cooperate with and carry out the home program assigned to me. If I have difficulty with any part of my treatment program, I will discuss it with my therapist.
1. The purpose, risks, and benefits of this evaluation have been explained to me.
2. I understand that I can terminate the procedure at any time.
3. I understand that I am responsible for immediately telling the examiner if I am having any discomfort or unusual symptoms during the evaluation.
4. I have the option of having a second person present in the room during the procedure and choose refuse this option.
Yes Choose
Yes Refuse
Date
Patient Name
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