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Patient Information

Date _________________________ PLEASE PRINT CLEARLY

Name____________________________________________________ Birthdate_________________

Last First M.I. MM/DD/YYYY

Age________ Sex M / F Marital Status ___________SS#____________________________ Address________________________________________City___________________Zip__________ Phone (____)________________Work (____)_________________Cell (____)__________________ Email__________________________________________________________________

********************************************************************************** Emergency Contact _______________________________ Relationship_______________

Phone (______)____________________________

Was Injury Personal Accident Yes / No Auto Related Yes / No Employment Related Yes / No Prior Physical Therapy THIS YEAR: Yes / No

If YES please indicate:

Last date of treatment __________________________ # of Visits __________________

Facility Name/Location______________________________________________________________ Ph (_____)_________________________

Are you currently receiving / received in the last 30 days Home Health from anyone for any procedure? Yes / No


Contact___________________________________ Phone (______)______________________ ********************************************************************************** Responsible Party Information (if other than above or Minor under 18yrs)

Name__________________________________________Employer___________________________ D.O.B. ________________________ Relationship to Patient_________________________________ Address_______________________________City:_________________________ Zip:___________ SS# ____________________ Phone (______)_______________________





Thank you for choosing Del Mar Physical Therapy for your physical therapy services. Please be aware that Del Mar Physical Therapy is a separate organization from the physician who referred you to us for treatment.

As a courtesy to our patients, we will bill approved Auto Insurance companies. All necessary billing information must be supplied on or before your initial

appointment. This includes a completed insurance information form with proof of a claim number, adjuster’s name and phone number and a prescription from your physician. You have a direct contract with your Auto Insurance with which we are not a party. In most cases, patients have Med Pay which covers their visits up to a specific amount. Treatments beyond the Med Pay amount will be billed to the patient. We make every effort to track the Med Pay limit but ultimately it is the responsibility of the patient.

Del Mar Physical Therapy cannot bill third party claims so if you have no Med Pay coverage we will not be able to bill the auto insurance company of the other party involved in your accident.

24 hour notice must be given for cancellation of scheduled appointments. Failure to do so will result in a $30.00 cancellation fee which must be paid by your next appointment. This fee cannot be billed to any insurance.

Accounts with outstanding balances are reviewed and processed by Green Profit Recovery for collection.

We reserve the right to change or cancel any appointment as is necessary. On these occasions, every effort will be made to reschedule you at your convenience. I have read and understand the above policies and procedures.

_______________________________________ ____________

Patient Signature Date



Primary Insurance Information

Circle One: Worker’s Comp Private Insurance Auto

Insured’s Name________________________________________ Policy#_______________________ D.O.B.__________________

Insurance Co. Name_________________________________________

Group#______________________Subscriber/relation___________________________________ HMO / PPO / POS / EPO

In Network Benefits

Deductible $___________ Calendar Year: Yes / No Deductible Met $________

O/O/P $________Met $________CoPay $________ Ins. Pays___________% Co-Ins___________% Referral Required? Yes / No

Max Visits per Yr__________ #Visits used to Date________

Out of Network Benefits

Deductible $___________ Calendar Year: Yes / No Deductible Met $________

O/O/P $________Met $________CoPay $________ Ins. Pays___________% Co-Ins___________% PreCert Required? Y / N

Max Visits per Yr__________ #Visits used to Date________

I hereby instruct and direct that the above stated insurance company remit payment directly to:

Del Mar Physical Therapy 317 14 th Street

Del Mar, CA 92014


If my current policy prohibits direct payment to the therapist, I will hereby instruct and direct the insurance company to make out the check to me and mail as follows:

C/O Del Mar Physical Therapy 317 14 th Street

Del Mar, CA 92014


The payment issued by my insurance company to provider will not exceed my indebtedness to the above mentioned assignee, and I have agreed to pay in a timely manner, any balance of any and all professional service charges over and above the insurance payment and my benefits have been explained to me. A photocopy of this Assignment shall be considered as effective and valid as the original.

I also authorized the release of any information pertinent to my case to any insurance company, adjuster or attorney involved in this case.

I authorize therapist to file complaints directly to the California Insurance Commissioner, if the need arises.


Del Mar Physical Therapy


I have read and fully understand Del Mar Physical Therapy’s Notice of Information Practices. I understand that Del Mar Physical Therapy may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice. I also understand that Del Mar Physical Therapy will consider requests for restriction on a case by case basis, but does not have to agree to requests for restrictions.

I hereby consent to the use and disclosure of my personal health information. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.


INSURANCE BILLING INFORMATION Are we seeing you due to: (please check if any apply)

☐ Work-related injury ☐ Auto accident

☐ Home-related accident

☐ Other _______________________________________________________________ What is the date of your injury? ______________

What is the name of your insurance company? _________________________________ Do you have a claim number? ☐ Yes ☐ No

If you answered yes, please enter your claim number here: ________________________ Adjuster’s Name _______________________________ Phone number ____________ Insured’s Name ________________________________ Relationship ____________ How would you like us to bill for your treatment?

☐ Workers’ Compensation ☐ Private Insurance

☐ Bill you personally

☐ Automobile Insurance ☐ Medicare

Please give us a brief description of your accident, including when, where and how it happened:



Please complete this questionnaire prior to your appointment.

NAME: ______________________________________________ AGE: _______ DATE: _____________ PHYSICIAN: _______________________________ OCCUPATION: _____________________________


Please check if you have had any of the following:

☐ Advice from MD not to exercise ☐ Arthritis ☐ Back Injury ☐ Bladder/ Bowel Dysfunction ☐ Breathing Problems ☐ Cancer

☐ Circulation Problems ☐ Cold Hypersensitivity ☐ Dermatitis, Rashes

☐ Diabetes ☐ Dizzy Spells ☐ Eye Problems

☐ Fever (currently) ☐ Frostbite (area of the body) ________________________________

☐ Fractures ☐ Headaches (recurrent) ☐ Heart Problems

☐ High Blood Cholesterol ☐ High Blood Pressure ☐ HX of Heart Disease before 55

☐ Malignancies ☐ Motor Vehicle Accident ☐ Nerve Damage

☐ Osteoporosis ☐ Pregnancy (last 3 months) ☐ Raynaud’s Disease

☐ Respiratory Problems ☐ Seizures ☐ Stroke

☐ Swelling ☐ Tingling/ Numbness ☐ Whiplash

☐ Other medical problems ___________________________________________________________________ Have you ever had any surgeries? _____When? ________ Name of Surgery ___________________________

When? ________ Name of Surgery ___________________________

Do you have any metal in your body (other than in your teeth)? Yes ______ No ______ Do you have a cardiac (heart) pacemaker? Yes _____ No ______

Do you have trouble with your vision? Yes ______ No ______

List any allergies you have ___________________________________________________________________ List any medications you are now taking: _______________________________________________________ Have you ever had any physical therapy treatments before? Yes ______ No ______

If yes, indicate when and condition treated _______________________________________________________ Do you have, or have you had in the past, any of the following that would affect your current condition?

Pain, injury, fracture or sprain to:

☐ Ankles ☐ Back ☐ Buttocks ☐ Elbow ☐ Fingers

☐ Forearm ☐ Head ☐ Hip ☐ Jaw ☐ TMJ

☐ Neck ☐ Shin ☐ Shoulder ☐ Wrist ☐ Knees


Patient Health Questionnaire - PHQ

Patient Name Date

1. Describe your symptoms

Patient Signature Date

5. During the past 4 weeks:

Indicate where you have pain or other symptoms

6. During the past 4 weeks how much of the time has your condition interfered with your social activities?

(like visiting with friends, relatives, etc)

ACN Group, Inc. Use Only rev 7/18/05

Not at all A little bit Moderately Quite a bit Extremely

7. In general would you say your overall health right now is...

Good Fair Poor

Excellent Very Good

2. How often do you experience your symptoms?

Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day)

4. How are your symptoms changing?

Getting Better Not Changing Getting Worse

3. What describes the nature of your symptoms?

Sharp Dull ache Numb Shooting Burning Tingling

8. Who have you seen for your symptoms? No One Chiropractor

Medical Doctor Physical Therapist


b. What tests have you had for your symptoms

and when were they performed? Xrays

CT Scan Other

9. Have you had similar symptoms in the past? Yes No

a. If you have received treatment in the past for the same or similar symptoms, who did you see?

10. What is your occupation? Professional/Executive

White Collar/Secretarial Tradesperson Laborer Homemaker FT Student Retired Other

a. If you are not retired, a homemaker, or a student, what is your current work status?

MRI This Office Chiropractor Medical Doctor Physical Therapist Other Full-time Self-employed Unemployed Off work Part-time Other

a. What treatment did you receive and when?

date: date:

date: date: a. When did your symptoms start?

ACN Group, Inc. - Form PHQ-202

All of the time Most of the time Some of the time A little of the time None of the time

b. How did your symptoms begin?

b. How much has pain interfered with your normal work (including both work outside the home, and housework)

a. Indicate the average intensity of your symptoms





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