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undersigned, do hereby outhorize my insuronce
corrier(s) to poy direcily to pnoRehob physicol
Theropy, the insuronce benefits, if ony,
otirerwise poyable to me for services rendered. f understond
thot r om financiolly responsrble.for ony chorges
not covered by soid insuronce cornier(s), including co-poy
ond/ondeductibleomounts.,
J,fheundersignld,ogree]opoyolloftorneyfees,courtcosts,filingfees,
including chorges or commissions thot
moy 6e ossessed to me by ony collection ogency
retoined to pursue
suchmotters. Ifurtherogreetopoyinterestintheonount"i
doys'
r
do hereby give my permission to ProRehob.Physical
ond oll informotion pertoining to my
medicol necords
f.Si.p..^onthononybolonceovergO
Therofylilu.nirn
my insunonce corrier(s) ony
I
,F.-L
ProRehab
Physical Therapy
/.7
BookCliff Medical Plaza
590 East 100 North Suite #l
Price, Utah 84501
F.ax: (43S) 613_150l
PATIENT ilAME:
DOB:
DOCTOR NAME:
REASON FOR VISIT:
What body paft is invobed? (plcase check all
that apply below)
nser;
s.
olf t":,
Ankle:
F
Knee:
shourder:
.Typ.
DR Drl wrist:
=1
o/t Eurggry
for
.vt er.tlrrr
currrnt eensttron:
Tjlji']I
_ ^Dat of Inl.rrnlnlql due to acddcnt?_-_Expldn:--
how severe is your paln:
What is the oualitv of your
SurgCry Date:
uo you
have
Do trl
paln:
DBruising
flSharp
5* nr.l other:
Datc pdn Innt.rcd ror Non
rrv..
Ery|ain|fcurrcntGondllton|.ductoep'lv|o0,,|..;,,p-.-Howlo.g havcyou hrd curc.t Dtln?_--
OnascaleotO:@
Et Et
i:::, E_ o,l :,,:",r,
Ei !'-l
Eil Neck:
n
I o"ru,r, o
Fl
Eil t'es:
9l Dtl
n3 tra
Doutt Dstabblng
RIGHT. LEFT
%
%
c12
lnlury:_
.rrrsr,._
trs
DThrobbtng
Os
o7
Oaching
D8 D9
D1o
OBurning
way EHands reeting clfrt
O Locking/Catching
thefollowing? ENumbness
fJPoor Balance
Dloss
of Control of Bladder
DTingling
Dr pr have e ptce takcr?
Wdght:_
h pu currentty recclvlng llornc l{calth Serwlcet: l{clght:._-lf yea
DJoints Glving
DWeakness
Dswellrng
Where?
t'ro you have any history of an
ailergic reaction
DNo known
allergies
to medications or other substances?
Eyes,
specify:
Are you currently ta-kint any of the
following medicatlons? ]t so, indlcate bl marking
the check box nen to the medira
DOSE (include strength and
NAME OF MTDICATION
NAME OF MEDICATION
number of pills per dav
r.
7.
2.
U.
3.
9.
4.
10.
5.
I.t
6.
t2.
ls your injury/condition a result of a work related
incident?
ls your injury/condition a result of a motor vehicle
...id.rrt?Pfease list any compfication with your current
condition .i
PATIENT
SIGNATURE:
DATE:
-
DOSE (include
strength and
number of oills ner
.t:.
L -.
/-r--
'2':.--
/
proRehab
Physical Therapy
-BookCliff Medical plaza
590 East 100 North Suite #l
Price, Utah 84501
,/
Fax: (435) 613_ls0t
PAYMENT AGREEMENT
VWe agree to pay all charges and fees incurred herein as shown
by the statements,
promptly upon presentment thereof, unless credit arangements
are agreed upon in writing.
Charges shown by statements are deemed to be correct
and reasonable unless irotested in writing
within thirty days of billing date. If this account becomes delinquent,
VWe agree to pay interest
on the unpaid balance at the rate of | %%per month (ls%per
annum). I/tyefurther agree to
pay all court costs, attornqt'sfess and collection
agenc), commissions
incuned in collecting
this account, whether ot not suit isJiled, and understand
that collection agency commissions
might be as much as S0% of the principal balance owing.
DATED this
day
of
2A,
PATIENT
GUARANTOR
GUARANTOR
*l
'2t,.,"(,p.,I
Lt*
Michael Gagon, Vice president
HlpAA Compliance Form
l, thc undcnigncd, do hercby acknowrcdgc
that I war ma.re aware of thc
PRAcrlcEs bv ProRehab Ptnaical
T[,.tpy
d""";.";, ;;; @ my total
compliaricc with them' I undcrrtana
-,a
""d,;J;;*J
tl"t it c po"ti"cr".r,tiilr,i.a u, HrpAA arc for thc protection
perronal rncdical rccondr in compliancc
of
with currcrrt h*l;;ize
that proRchab phyeicar Therapy
rercFvcr thc right to
'change thcii prtvacy practicer and termr per thcir
dircretion, providcd that said
changcr arc pcrmittcd bv law. | tufth;;i.-;;;;:.ilIi"a
pbaicar Thcrapy hae
the right to
6 -"' thc patient,-t w"nt that
with the privacy
lll:H;ffir:i;*mmprwidcd
Simcd
"r
Datc
"o-pri.,