PureHealth - Patient Intake Form

Patient & Insurance

Fields marked * are required.

Patient Information

First Name *

Middle Name

Last Name *

Street Address *

ZIP Code *

City *

State *

Date of Birth *

Home Phone

Work Phone

SSN

Sex

M F Other

Marital Status

Race / Ethnicity

Employer

Emergency Contact

Name *

Relationship *

Home Phone *

Work Phone

Responsible Party (if different)

Name

Relationship

Home Phone

Work Phone

Primary Insurance

Insurance Company *

Group #

Subscriber Name

Co-Pay

Phone

Secondary Insurance (if applicable)

Insurance Company

Group #

Subscriber Name

Co-Pay

Phone

Workers Compensation (if applicable)

Carrier

Case #

Injury Date

Contact Person

Physician

Physician Phone

Employer Phone

Medical History

Federal and State Regulations require a medical history in patient records.

Date *

OP Medical Record #

Referring Physician

Reason for Referral *

Date of Onset / Injury / Surgery

Check all that apply

If yes to any above, explain and give dates

Medications

Currently taking medications?

Yes No

If yes - medication / dosage / condition

Previous therapy for this condition?

Yes No

Work-related injury?

Yes No

Injury reported to employer?

Yes No

Consents and Agreements

Initial each section below.

Financial Responsibility

Initials

I guarantee payment of therapy services. Co-payments are due at time of service. Balances remaining after insurance payment are due upon receipt.

Late Payment and Collection

Initials

Interest of 1.5%/month (18%/year) on accounts 30+ days past due. Attorney fees and collection costs apply if sent to collections.

Cancellation Policy

Initials

24-hour notice required to cancel. A $25.00 fee may be charged for insufficient notice.

Treatment Consent

Initials

I consent to examinations, treatments, and medications ordered by my physician or alternate.

Release of Information and Insurance Assignment

Initials

I authorize release of clinical information for claims. Insurance benefits assigned to facility. Responsible for 20% of Medicare Part B.

Photo, Video and Media Consent

Clinical Photography and Video

Initials

Consent for photos/video for identification, clinical documentation, and treatment progress. Stored securely in medical record.

Activities Photography

Initials

Photos/video during facility activities for internal use only.

I Consent I Do NOT Consent

Social Media and Marketing

Initials

I authorize PureHealth to use my image for (check all that apply):

Social media Website and online content Printed marketing materials Internal communications and training News media and press releases

Privacy Practices

Notice of Privacy Practices - Summary

PureHealth uses your health information to provide care, process payments, and operate our facility. Your information may also be used for communications with family/representatives, workers compensation, law enforcement, public health as required by law, and appointment reminders.

You may request restrictions on use of your information
You may access, copy, and request amendments to your records
You may file complaints with us or the Secretary of HHS without retaliation

A full copy of our Notice of Privacy Practices is available upon request.

I acknowledge receipt of PureHealth's Notice of Privacy Practices and understand how my health information may be used and disclosed.

Full Agreement Acknowledgement

Initials

I have read this agreement in its entirety and agree to all terms and obligations herein.

Signatures

Sign using mouse, stylus, or finger on the pad below.

Patient or Legal Guardian

Sign here...

Date *

Printed Name *

Responsible Party (if different)

Sign here...

Date

Relationship

Media and Privacy Consent

Sign here...

Date *

Ready to Submit Your completed form will be sent securely to your site's rehabilitation staff.

Outpatient Therapy Intake

Financial Responsibility

Late Payment and Collection

Cancellation Policy

Treatment Consent

Release of Information and Insurance Assignment

Clinical Photography and Video

Activities Photography

Social Media and Marketing

Notice of Privacy Practices - Summary

Full Agreement Acknowledgement

Patient or Legal Guardian

Responsible Party (if different)

Media and Privacy Consent

Form Submitted!