NEW PATIENT REGISTRATION

Personal Information

Last Name: _________________________________________

First Name: _________________________________________
Address: ___________________________________APT#_______
City : ___________________ State: _________ Zip: ________
Home#: (_____)_______________Work#(_____)____________
Cell#: (_____)______________ Fax# (_____)____________
E-mail: _____________________________________________
Appointment Reminder: Email ( ) or Text ( ) carrier:_____________
Social Security Number: ____________ Marital Status: M S W
Sex:
M
F
Date Of Birth: ____________
Referring Physician: ___________________________________

Employment Information
Employer: ______________________________________________________
Employer Address: _______________________________________________
Responsible Party: Self / Other
(If other) Name: _________________
Address: ________________________________ Phone: ________________

Insurance Information
Name of Insured: _________________________________________________
SS# of Insured: __________________________________________________
Insurance Carrier: ____________________ Phone: ______________________
Policy #: ____________________________ Group #: _____________________

In Case of Emergency
Name: __________________________________________________________
Relationship: _____________________________________________________
Phone: __________________________________________________________

PATIENT MEDICAL HISTORY FORM

Name: _______________________________________________

Age:_____________

Current Concern/Problem:___________________________________Onset:_______
Have you ever been diagnosed with the following conditions:
Circle YES or NO
If YES, please explain in the space provided below
Cancer
Thyroid Conditions

YES
YES

NO
NO

Anemia
Stroke

YES
YES

NO
NO

Pacemaker

YES

NO

DVT

YES

NO

High Blood Pressure

YES

NO

Migraines

YES

NO

Heart Attack

YES

NO

Osteoporosis YES

NO

Heart Condition

YES

NO

Diabetes

YES

NO

Fever/Night Sweats

YES

NO

Dizziness

YES

NO

Deep Venous Thrombosis

YES

NO

Pneumonia

YES

NO

Metal Implants

YES

NO

Asthma

YES

NO

Circulation Problems

YES

NO

Seizures

YES

NO

Osteoarthritis

YES

NO

Other

YES

NO

Rheumatoid Arthritis

YES

NO

Please describe YES answers:______________________________________________

________________________________________________________________________
________________________________________________________________________

Medications you are currently taking (including over-the counter medications):

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Have you had Physical Therapy before? If so, please describe type and results of
treatment______________________________________________________________

Physical Therapy Patient Agreement

Thank you for choosing James Fowler Physical Therapy. Please read and sign the following
agreement. If you have any questions, please ask for clarification.

.
1.

Payment of all fees is expected at time of service or via credit card on file. We will assist
you in submitting claims to your insurance carrier. However, you are still responsible for
any deductible, co-insurance/co-payments or claim denied by your insurance carrier.

2.

I hereby authorize James Fowler P.T., P.C., having treated me, to release to government
agencies, insurance carriers, and all others who are financially liable for my care, all
information needed to substantiate payments for care and to permit representatives
thereof to examine and make copies of all records related to such care and treatment. I
understand that if at any point my insurance coverage changes, I am to notify the staff
prior to my next visit. Failure to do so will result in my being responsible for the full
amount of services.

3.

A scheduled appointment must be canceled at least 24 hours in advance or a $150.00

Late Cancel Fee will be assessed. Similarly, if you do not show up for a scheduled
appointment, a $150.00 fee will be assessed. The fee is not billable to any insurance
carrier.

4.

I authorize all payment of medical benefits directly to James Fowler P.T., P.C. for the
services rendered. I agree to be responsible for all deductible and co-payments fees

I have read, understand, and agree to all the above terms.

______________________________________________
or authorized representative
Date

_____________ Signature of patient

Patient Insurance Coverage

Date: _________

Patient: ___________________________________________________________
We have verified your commercial insurance coverage and would like to make sure you fully understand your
benefits. Please take a moment to review the following information:

1) Patient Benefits/Coverage:
__________ Visits per condition per calendar year/lifetime
__________ Consecutive days per condition per calendar year/lifetime
__________ Visits per cal year based on medical necessity and subject to review
__________ Deductible amount
__________ Deductible met to date
__________ Deductible to be paid by patient

2) Patient Co-Payment of $__________ per visit

Initial Eval = __________________________
Follow-up = __________________________

I have read and understood these conditions.

Signed ________________________________________________ Date ____________________

Patient Privacy
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY
Effective April 14, 2003
The privacy of your medical information is important to us. You may be aware that U.S.
government regulators established privacy rule (HIPAA) governing protected health
information. This notice tells you about how it may be used, and about certain rights that you
have.
James Fowler, P.T. is in charge of privacy matters at our facility. You can contact him at (212)
253-9383 if you desire further information, or have any questions or concerns.
Use and disclosure of protected information:
Federal law provides that we may use your medical information (protected health information)
for treatment of you, without further specific notice to you, or written authorization by you; for
example we may send your referring physician a copy of your initial evaluation or a periodic
progress report to let them know how your care is progressing.
Federal law provides that we may use your medical information to obtain payment for our
services without further specific notice to you, or written authorization by you; for example most
insurance carriers require a copy of your documentation to pre-certify care, extend care and
review specific claims for payment.
Federal law provides that we may use your medical information for health care operations
without further specific notice to you, or written authorization by you; for example are
accountants may see your name, dates of treatment and procedure codes during audits or our
records.
We may use or disclose your medical information, without further notice to you, or specific
authorization by you, where:
1.
2.
3.
4.

required by law;
required for public health purposes;
required by law to report child abuse;
Where required by a health oversight agency for oversight activities authorized by
law, such as the Department of Health, Office of Professional Discipline or Office of
Professional Medical Conduct.
5. required by law in judicial or administrative proceedings;
6. required by law enforcement purposes by a law enforcement official;
7. required by a coroner or medical examiner;

8. permitted by law to a funeral director;

9. permitted by law for organ donation purposes;
10. permitted by law to avert a serious threat to health or safety;
11. permitted by law and required by military authorities if you are a member of the
armed forces of the United States; 12. research purposes

New York State law provides additional protection for information regarding HIV/AIDS. We
will continue to follow New York State law with respect to such information.
We may contact you by mail or phone, at your residence, to remind you of appointments or to
provide information about treatment alternatives. Unless you instruct us otherwise, we may leave
a message for you on any answering device or with any person who answers the phone at your
residence.
You can make reasonable requests, in writing, for us to use alternative methods of
communicating with you in a confidential manner. Space for this is provided below.
Other uses or disclosures of your medical information will be made only with your written
authorization. You have the right to revoke any written authorization that you give.
Your Rights:
You have the right to request restrictions on certain of the uses or disclosures described above.
Except as stated below, we are not required to agree to such restrictions.
You have the right to inspect and obtain copies of your medical information (a reasonable fee
will be charged).
You have the right to request amendments to your medical information. Such requests must be in
writing, and must state the reason for the requested amendment. We will notify you as to
whether we agree or disagree with the requested amendment. If we disagree with any requested
amendment, we will further notify you of your rights.
You have the right to request an accounting of any disclosures we make of your medical
information, except for: disclosures we make to you, or to carry out treatment, payment or health
care operations, or as requested by your written authorization, or as permitted or required under
45 CFR 164.502, or for emergency or notification purposes, or for national security or
intelligence purposes as permitted by law, or to correctional facilities or law enforcement
officials as permitted by law (or for research or public health purposes after being de-identified or
limited to remove personally identifiable information) or disclosures made before April 14, 2003.
Our Obligations:
We are required by law to maintain the privacy of protected health information and to provide
individuals with notice of our legal duties and privacy practices.

We are required to abide by the terms of this notice as long as it is currently in effect.
We reserve the right to revise this notice, and to make a new notice effective for all protected
health information we maintain. Any revised notice will be posted in our facility, and copies will
be available there.
If you want to complain about violations of your privacy rights, you have the right to file a
complaint with the Sectretary of the Department of Health and Human Services of the United
States. You may also file a complaint with us. Complaints should be directed to
James Fowler, P.T., P.C.
873 Broadway, Suite 510 New
York, NY 10003
(212) 253-9383
No retaliatory action will be taken against you for any complaint you may make.

I have received a paper copy of this notice

_________________________________
Signature
_________________________________
Print Name
_________________________________
Date
I make the following special request for confidential communications:

_____________________
Signature

____________
Date

CREDIT CARD ON FILE AGREEMENT

In order to expedite billing, we keep a credit card on file. Your credit card
will be billed weekly for any balance and you will receive a paid invoice
and receipt.
________________________________________
__________
Name
Date
Credit Card Type:
Visa

Master Card

Discover

Card #____________________________________ Exp: _______

I authorize James Fowler Physical Therapy to charge this card for any
balance on file.
Amount to be charged:
1st visit: $_________ (patient initial_______)
Each follow up visit: $_______ (patient initial ______)

Signature: _______________________________________