ME N D OCINO PHYSICAL THERAPY

846 S. Dora Street Ukiah, CA 95482 Phone: (707) 462-9784

PATIENT INFORMATION
Date: ___ / ___ / 20_____ Name: __________________________________________________________________________________ (Last, rst, middle) DOB: ___ /___ /______ Age: _____ Marital Status: ____________________ Alternate #: ___________________

Phone (preferred contact number): _____________________

Email address: ___________________________________________________________________________ Address: _________________________________________________________________________ (Street/City/State/Zip) How do you wish to receive appointment reminders: by _____ phone, _____ text or _____ email EMPLOYMENT INFORMATION: Employer: ________________________________________ Occupation: ___________________________ Street Address: _______________________________ Apt./Ste. ___ City ______________ Zip ________ PLEASE PRESENT YOUR INSURANCE CARDS TO RECEPTIONIST. IF WORKMANS COMP: Industrial Carrier Company _________________________________________ Claim No. ________________ Date of Injury: ________________________________________________ Zip ________

Billing Address: City _______________________________

I hereby authorize Mendocino Physical Therapy to utilize photography and/or cinematography to demonstrate the biomechanics of movement and/or illustrate a home program of exercise (HEP) Patient Signature: ____________________________________ Date _____ / _____ / 20_____ I authorize payment of medical benefits from my insurance carrier to Mendocino Physical Therapy. Patient Signature: ____________________________________ Date _____ / _____ / 20_____ What is your primary reason for seeking physical therapy? ________________________________ _________________________________________________________________________________________

ME N D OCINO PHYSICAL THERAPY

846 S. Dora Street Ukiah, CA 95482 Phone: (707) 462-9784

PATIENT HISTORY
Please indicate on the drawing where you feel your symptoms: Key: Pins & Needles = 0000 Stabbing Pain = ///// Aching Pain = zzzz Burning = xxxx

When did this begin? ________________________________________________________________ Are your symptoms (circle one): getting better, staying the same, or getting worse? Have you had any surgeries performed? Describe. ____________________________________ _____________________________________________________________________________________ Do you currently have any trouble with the following activities? Circle all that apply. Sitting Sleeping Shopping Lifting Driving Housekeeping Working Recreational Activities Bending Standing Stairs Walking Bathing Running Grooming

ME N D OCINO PHYSICAL THERAPY

846 S. Dora Street Ukiah, CA 95482 Phone: (707) 462-9784

Using this scale,

please answer these questions: What is your current pain level? What is your pain level at worst? What is your pain level at best? ______ / 10 ______ / 10 ______ / 10

What makes your symptoms better? ________________________________________________________ ___________________________________________________________________________________________ What makes your symptoms worse? ________________________________________________________ ___________________________________________________________________________________________ Has anything like this happened before? ____________________________________________________ ___________________________________________________________________________________________ What treatment have you received for this problem? ________________________________________ ___________________________________________________________________________________________

What is your current living situation? Circle all that apply. Spouse Family Roommate Other

How many stairs do you have at your home? _______________ Do you have a railing? _________ What is your occupation? __________________________________________________________________

ME N D OCINO PHYSICAL THERAPY

846 S. Dora Street Ukiah, CA 95482 Phone: (707) 462-9784 Do you currently use tobacco products? Yes or No (circle one) How many falls have you had in the last year? ______________________________________________ Have you or a family member experienced any of the following? Check all that apply. ___ Osteroarthritis (Self/Family) ___ Rheumatoid Arthritis (Self/Family)

___ Cardiovascular Disease (Self/Family)

___ Allergies/asthma (Self/Family)

___ Pacemaker (self) ___ Debrillator . ___ High Blood Pressure (Self/Family)

___ Latex allergy (self)

___ Incontinence (Self/Family)

___ Angina/Chest Pain (Self/Family)

___ Osteoporosis (Self/Family)

___ Stroke (Self/Family)

___ Cancer (Self/Family)

___ Diabetes Mellitus Type I (Self/Family)

___ Lung Disease (Self/Family)

___ Diabetes Mellitus Type II (Self/Family)

___ Liver Disease (Self/Family)

___ Seizures (Self/Family)

___ Fibromyalgia (Self/Family)

Have you had any imaging performed? X-ray, CT, MRI, etc. _________________________________ ___________________________________________________________________________________________

ME N D OCINO PHYSICAL THERAPY

846 S. Dora Street Ukiah, CA 95482 Phone: (707) 462-9784 Please list all current medications and supplements you take, including vitamins, prescriptions, injections, over-the-counter drugs, herbs, etc. ___________________________________________________________________________________________ ___________________________________________________________________________________________

Have you experienced any of the following? Check all that apply. ___ Pain with cough/sneeze ___ Pain with bowel movement ___ Fatigue/malaise ___ Weakness ___ Dizziness ___ Nausea/vomiting

___ Unexplained weight loss/gain ___ Recent fever and chills

___ Recent change in bowel or bladder Are you currently pregnant? ___ Yes ___ No

To the best of my knowledge, the information above is correct. ___________________________________________________________ Signature Date ____ / ____ / 20____

ME N D OCINO PHYSICAL THERAPY

846 S. Dora Street Ukiah, CA 95482 Phone: (707) 462-9784

NOTICE OF PRIVACY PRACTICES

This notice describes how medical information may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions, please contact Mendocino Physical Therapy.

WHO WILL FOLLOW THIS NOTICE This notice describes the practices of Mendocino Physical Therapy and that of all employees, staff, and other designated personnel (e.g., students, contracted agency staff).

OUR PLEDGE REGARDING MEDICAL INFORMATION We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive in our facility. We need this record to provide you with the quality of care and to comply with certain legal requirements. This notice will tell you about the ways in which we may use and disclose medical information about you, via any medium (written, oral, or electronic). We also describe your rights and certain obligations we have regarding the use and disclosure of medical information. We are required by law to: make sure that medical information that identies you is kept private give you this notice of our legal duties and privacy practices with respect to medical information about you follow the terms of this notice already in effect

ME N D OCINO PHYSICAL THERAPY

846 S. Dora Street Ukiah, CA 95482 Phone: (707) 462-9784

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe the different ways that we use and disclose medical information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use of disclosure in a category will be listed. However, all the ways we are permitted to used and disclose information will fall within one of the categories Treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you. We also may disclose medical information about you to others who may be involved in your medical care, such as caregiver, clergy, or others we use to provide services that are part of your care. Payment: We may use and disclose medical information about you so that the treatment and services you receive may be billed and collected from you, the party responsible for you bill, an insurance company or third party. For example, we may need to give your health information about treatments you receive so your health plan will reimburse us or you. Health care options: We may combine the medical information about you that we have with medical information from other health care agencies to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specic patients are. Appointment reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical services. Treatment alternatives: We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be important to you. Health-related benets and services: We may use and disclose medical information to tell you about health-related benets or services that may be of interest to you. To avert a serious threat to health and safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public, or another person. Any disclosure, however, would only be to someone able to help prevent the threat. For example, if you were involved in a violent crime, disclosure may be made to law enforcement.

ME N D OCINO PHYSICAL THERAPY

846 S. Dora Street Ukiah, CA 95482 Phone: (707) 462-9784

SPECIAL SITUATIONS Military and veterans: If you are a member of the armed forces or a veteran, we may release medical information about you as required by military command authorities. Workers compensation: We may release medical information about you to your workers compensation program for work-related injuries or illness. Public health risks: We may disclose medical information about you for public health activities. These activities generally include the following: o to prevent or control disease, injury, or disability o o o o o to report abuse or neglect of children, elders, dependent adults to report reactions to medications or problems with products to notify people of recalls or products that may be using to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition to notify the appropriate government authority if we believe a patient has been the victim or abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law. Health oversight activities: we may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Lawsuits and disputes: if you are involved in a lawsuit or dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to subpoena, discover request, or other lawful process by someone else involved in the dispute. Law enforcement: we may release medical information if asked to do so by a law enforcement official... o in response to a court order, subpoena, warrant, summons, or similar process o to identify or locate a suspect, fugitive, material witness, or missing person o about the victim of a crime if, under certain circumstances, we are unable to obtain the persons agreement o about a death we believe may be the result of criminal conduct o about criminal conduct at the facility o in emergency circumstances to report a crime; the location of the crime or victim; or the identity, description, or location of the person who committed the crime

ME N D OCINO PHYSICAL THERAPY

846 S. Dora Street Ukiah, CA 95482 Phone: (707) 462-9784

National security and intelligence activities: we may release medical information about you to authorized federal officials for intelligence, counterintelligence , and other national security activities authorized by law.

Inmates: if you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU You have the following rights regarding medical information we maintain about you: Right to inspect and copy: you have the right to inspect and receive a copy of the medical information that may be used to make decisions about your care. Usually, this includes medical and billing records. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to us. If you request a copy of the information, we may charge a fee for costs of copying, mailing or other supplies associated with your request. Right to amend: if you feel the medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we keep the information. Right to an accounting of disclosures: you have the right to request an accounting of disclosures. This is a list of the disclosures we made of medical information about you other than our own uses for treatment, payment, and health care operations, as those functions are described above. To receive this list or accounting of disclosures, you must submit your request in writing to us. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want this list (for example, on paper or electronically). We may charge you for the costs of providing the liest. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. Right to request restrictions: you have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the

ME N D OCINO PHYSICAL THERAPY

846 S. Dora Street Ukiah, CA 95482 Phone: (707) 462-9784 payment for your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or if the law requires disclosure. To request restrictions, you may make your request in writing to us. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit; (3) to whom you want the limits to apply [for example, disclosures to your spouse]. Right to request condential communications: you have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request condential communications, you must make your request in writing to us. We will not ask you for the reason for your request. While we are not required to agree to your request, we will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. Right to a paper copy of this notice: you have the right to have a paper copy of this notice at any time. CHANGES TO THIS NOTICE We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the facility. The notice will contain on the rst page, in the top right-hand corner, the effective date. If the notice is changed, we will offer you a copy of the revised notice upon your request. COMPLAINTS If you believe your privacy rights have been violated, you may le with our office or with the secretary of the department of health and human services. To le a complaint with this facility, contact the privacy official of the office. All complaints must be submitted in writing. You will not be penalized for ling a complaint.

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ME N D OCINO PHYSICAL THERAPY

846 S. Dora Street Ukiah, CA 95482 Phone: (707) 462-9784

OTHER USES OF MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to you.

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ME N D OCINO PHYSICAL THERAPY

846 S. Dora Street Ukiah, CA 95482 Phone: (707) 462-9784

PRIVACY PRACTICES ACKNOWLEDGMENT

I have received the notice of privacy practices and have been provided an opportunity to review it.

Name: ___________________________________________________ Date of Birth: _____/_____/___________

Signature: _______________________________________________ Todays Date: _____/_____/___________

In the event Mendocino Physical Therapy may need to give your test results or medical information, may we (check all that apply): _____ Leave a detailed message on an answering machine _____ Leave a message with your spouse or family member _____ Call your cell phone. If so, cell number is __________________________. _____ Call you at work. If so, the number is ______________________________. _____ Speak to you directly ONLY.

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ME N D OCINO PHYSICAL THERAPY

846 S. Dora Street Ukiah, CA 95482 Phone: (707) 462-9784

FINANCIAL POLICY
Thank you for choosing us as your health care provider. Please understand that payment of your bill is considered part of your treatment. Co-pays: All co-pays and deductibles are due and payable at the time of service. This is in accordance with the legal requirements prohibiting providers from writing off patient responsibility amounts. You agree to be responsible for your co-pay, due at the time of service, or your appointment may be rescheduled. Proof of insurance: You are responsible for providing Mendocino Physical Therapy with the correct insurance information. This is so we may bill your insurance company and receive payment in a timely fashion. You must bring your insurance card with you to each visit. We will bill your insurance company for you. However, you are responsible for payment, as well as for any balance after the insurance payment, with the exceptions noted above. Secondary insurance: We will bill your secondary insurance as a courtesy to you. However, you are still responsible for any and all unpaid balances. Unfortunately, we can only bill your secondary insurance company one time. Workers Comp: As a provider for this service, we treat work-related injuries. In the event we are not supplied with all necessary insurance information and authorizations, charges incurred for this treatment are the responsibility of the patient. Medicare and Medi-Cal non-covered procedures: Patients are responsible for any noncovered services they request and will be asked to sign a date-of-service waiver indicating the patients responsibility of payment. Refunds: If your account becomes overpaid, we will credit that account unless you request a refund. Non-sufficient funds: Checks received for payment of services and returned by the bank marked non-sufficient funds will be charged back to the patient with an additional $25 fee per incident. Collection accounts: Any account that goes to collection for non-payment will incur a collection charge of $20 in addition to the outstanding balance. No-show appointments: We understand that occasionally patients will be unable to make scheduled appointments due to emergencies. However, it is expected that the patient will notify Mendocino Physical Therapy within 24 hours of that appointment. Failure to notify our office in this circumstance will result in a charge of $35 being billed to your account. Name: (please print): ____________________________________________________________________ Signature: __________________________________________________ Date: ______________________

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