Patient Information
*Please fill out ALL information that applies to your condition including addresses and phone #’s*
Name:
Address:
Date:
City: __________ State: ______ Zip:
Employer:
Home Ph: (
)Address:
Cell Ph: (
)City: ___________ State: ___ Zip:
Phone: (_______) _________Voice mail OK? (circle if OK): Home Work Cell
S.S #: ______ / ______ / ______  M  F
Birth date:______/______/______ Age:
How did you hear about our facility?
Insurance Information
*Please include all private insurance information, even if L&I is your payer*
Health Insurance Company Name:
Address:
Phone:
-
Ins. Group #:
Ins. ID #:
Ins. Adjustor:
Relationship to Subscriber:
 Self
 Spouse
 Dependent
 Other
Subscriber Name:
Subscriber Birth date:
Subscriber Employer:
Is this insurance responsible for today’s charges?
Y
N
Labor and Industries Claim #: ________________
Is your claim:
 Open Closed
Are you in litigation?  Yes  No
Date of Injury: ________________________
Name of Adjustor: _____________________
Is this insurance responsible for today’s charges? Y N
Attorney Information
Do you have an attorney for this condition? Y
Attorney Name:
Law Firm Name:
Street Address: ___________________________
N
City/State: ___________________________
Zip: ________________________________
Phone: (______)_________-
In Case of Emergency, Please Contact:
Name: __________________________________
Evening Phone:
Day Phone: (____) ______- _________________
Relationship:
Contractual Agreement
Renaissance Physical Therapy
Clinic Policies
As a courtesy to our patients, we will prepare necessary reports and forms required for processing insurance
claims/bills. You are responsible to provide relevant information so we can process these claims. You, not
Renaissance Physical therapy hold the relationship with your insurance company and are therefore, ultimately
responsible for their performance.
According to the specific terms of your contract with the insurance carrier, you may be responsible for a portion of
treatment costs. Sometimes your responsibility comes in the form of a per visit co-pay, sometimes you are
responsible for a percentage of overall treatment costs. Note: If your insurance plan has a large deductible ($500
or more) Renaissance PT will collect from you at each visit a portion of the deductible until your deductible is met.
It is important that you understand what your insurance will cover and what your payment responsibility may be.
Renaissance Physical Therapy will issue a bill for any balance remaining after insurance payment, which you are
requested to remit in full within thirty days from the statement date.
If your insurance company denies payment, you are personally responsible for all outstanding charges.
If you suspend or terminate your treatment at Renaissance Physical Therapy all fees for services will become
immediately due and payable.
Interest will be charged on all overdue accounts at the rate of 12% Apr. If your account is turned over to collection,
the interest will terminate and your account will be charged a 50% one-time collection fee.
By signing below, you give this office power of attorney to endorse checks made out in your name, so that they
may be credited to your account.
Returned checks will be subject to a $25.00 fee.
Cancellation Policy
If you are unable to keep your appointment, you are required to notify the clinic 24 hours in advance. Failure to
provide this notice will result in a $35.00 charge to your account. This fee cannot be billed to your insurance
company – you are solely responsible for its payment.
If you miss three scheduled appointments without appropriate notification, Renaissance Physical Therapy has the
right to revoke your privileges in visiting these facilities, In such an event, your account balance becomes
immediately due and payable.
I certify that the information provided herein is true and correct to the best of my knowledge. I fully understand and
accept all the terms of this contract, and give my signature here as testimony to this full understanding and
acceptance.
Patient Signature
Date
Patient – Printed Name
Parent/Legal Guardian Signature (if applicable)
Consent for Purposes of Treatment, Payment & Healthcare Operations
I, _____________________________________ (patient name), consent to the use or disclosure of my
protected health information by Renaissance Physical Therapy for the purpose of providing treatment to me,
obtaining payment for my health care bills or to conduct health care operations of Renaissance Physical
Therapy. I understand that treatment received by a Physical Therapist may be conditioned upon my consent as
evidence by signing my signature on this document.
I understand I have the right to request a restriction as to how my protected health information is used or
disclosed to carry out treatment payment of healthcare operation of the practice. Renaissance Physical Therapy
agrees to any restriction that I request, the restriction is binding on Renaissance Physical Therapy and
Renaissance Physical Therapy employees.
I have the right to revoke this consent, in writing, at any time, except to the extent that Renaissance Physical
Therapy and its employees have taken action in reliance on this consent.
My “protected health information” means health information, including my demographic information, collected
from me and created or received by my Therapist, another health care provider, a health plan, my employer or
health care clearinghouse. This protected health information related to my past, present and future physical or
mental health or condition and identifies me, or there is a reasonable basis to believe the information may
identify me.
I understand that I have the right to review Renaissance Physical Therapy Notice of Privacy Practices prior to
signing this document. I certify that Renaissance Physical Therapy Notice of Privacy Practices has been
provided to me. The notice of privacy practices describes the types of uses and disclosure of my protected health
information that may occur in my treatment, payment of my bills in the performances of health care operations
of Renaissance Physical Therapy. The Notices of Privacy Practices also describes my rights and Renaissance
Physical Therapy’s duties with respect to my protected health information.
Renaissance Physical Therapy reserves he right to change the privacy practices that are described in the notice
of Privacy Practices. I may obtain a revised copy at the time of my next appointment, viewing it on the
Renaissance Physical Therapy website or asking that one be sent in the mail.
_________________________________
_________________________________
Printed Name of Patient
Date
_________________________________
_______________________________________________
Signature of Patient or Legal Guardian
Relationship to Patient (i.e., Parent, Guardian, Personal Representative)
INTAKE HEALTH QUESTIONAIRE
(This will help us understand your specific needs; please answer all that apply)
PLEASE BE AS COMPLETE AS POSSIBLE
Name: ______________________________________________________ Date: ________________________
Reason for seeking Physical Therapy: ___________________________________________________________
__________________________________________________________________________________________
Have you had a complete medical check-up within the last year? _____Yes _____ No
Do you now have anything contagious? _____Yes _____No
Please check if you now have or recently have had any of the following complaints?
____
____
____
____
____
____
Shortness of breath
Pain or a feeling of heaviness in your chest
Pulsating pain anywhere in your body
Constant and severe pain in lower leg (calf)
Discolored or painful feet
Dizziness
____
____
____
____
____
Persistent pain at night
Constant pain anywhere in your body
Unexplained weight loss
Unusual lumps or growths
Fatigue
____
____
____
____
____
____
____
Frequent or severe abdominal pain
Frequent nausea or vomiting
Problems with swallowing or changes in speech
Changes in vision (i.e. blurriness or loss of sight)
Problems with balance or falling
Fainting spells
Problems with coordination
____
____
____
Fever
Recent severe emotional disturbances
Swelling or redness in any joints
Are you now pregnant? _____Yes _____ No
Please check if you have or have had:
____ Diabetes
____ Heart Disease
____ Arthritis
____
____
____
High Blood Pressure
Cancer
Allergies, please list: ____________________
_____________________________________
If you have ever had spinal surgery, please describe and give approximate dates:_________________________
__________________________________________________________________________________________
Please list all medications you are currently taking: ________________________________________________
__________________________________________________________________________________________
What previous treatment have you received (or currently are receiving) for this injury or pain? ______________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
PAIN DRAWING
Mark the areas on these figures where you feel pain or sensations. Use the symbols as shown below. Indicate
radiating sensations by drawing an arrow from the origin (with appropriate symbol) to its furthest point.
Numbness = ###
Pins & Needles = ooo
Burning = xxx
Stabbing = \\\
Ache = <<<
Other: ____________________= +++
Renaissance Physical Therapy
20214 Ballinger Way NE
Seattle, WA 98155