OFFICE IN SCREENING
Have you traveled to an affected area within the last 14 days?
Have you had close contact with a confirmed COVID patient?
Do you have any of the following?
In case of an emergency who should be notified?
Have you received care from another Healthcare Professional for this injury?
Where is your problem? (Please circle all that apply for this visit)
Did you have surgery for this condition?
Which is your Dominant Arm?
Functional Limitations: (Please circle all that apply)
Home Layout: (please check all that apply)
Please indicate nature of your symptoms (Please circle only one)
How did you injure yourself?
Is there a Workers Comp Claim?
Are you currently working?
Patient Initial Intake Form
How severe is the pain (0=none, 10=severe pain)
Have you had similar symptoms in the past?
In general would you say your health right now is
Are you currently pregnant, or trying to become pregnant?
Do you have Latex Allergies?
Medical History: (please check all that apply)
Please list your medications, dose and frequency (please include any vitamins or over the counter medications)
ABOUT YOUR MEDICARE BENEFITS
The following are some facts you should be aware of regarding your Medicare Benefits for Physical Therapy:
1. This office is a participating provider of Medicare.
2. Medicare requires their beneficiaries to satisfy $206.00 yearly deductible before they will begin paying.
3. After your deductible is satisfied, Medicare will reimburse 80% of what they consider to be an "approved fee" providing they do not exceed the charges. An exclusion is a charge that is not covered by your Medicare Plan. Medicare states that in this case, the patient is responsible for the actual charge billed by the provider.
4. Effective 1/1/21 there is a Monetary Cap on Physical Therapy Benefits combined with Speech Therapy Benefits as well. The maximum dollar amount Medicare will allow is $2,110.00 of which they will pay 80% - ($1,688.00) and the member will be responsible for the remaining 20% - ($422.00).
5. On assigned claims, the beneficiary, who is the patient, is responsible for the co-insurance (20% of the approved charge), the deductible per calendar year and any exclusion.
6. To continue Physical Therapy past 30 days, Medicare requires that you return to your Primary Care Physician/ referring Physician within 30 days of your last dated prescription. To determine medical necessity for continued care WE WILL NEED AN UPDATED PRESCRIPTION EVERY 30 DAYS FROM THE PREVIOUS ONE TO ENSURE MEDICAL NECESSITY. THIS IS THE PATIENT'S RESPONSIBILITY.
7. If you are receiving any HOME CARE SERVICES from an agency, Medicare will not cover any services at our facility. Medicare stipulates that any patient who is receiving home care services (i.e. Home Health Aide, visiting nurse, etc) must receive all services through that agency. Please inform the front desk staff if you are currently receiving or plan to receive any HOME CARE SERVICES. Any claims denied for this reason will be your responsibility as you have been informed prior to treatment that this is not allowed by Medicare.
If you have any additional questions about your Medicare benefits, please ask one of the front office members of your Medicare Representative.
I have read the above regarding my Medicare benefits and understand my responsibility as the beneficiary/patient.
MEDICARE ASSIGNMENT FORM
ASSIGNMENT OF BENEFITS:
I request that payment of authorized Medicare benefits be made on my behalf to WILLIAM J. SCHWARZ, P.T., P.C. for any services furnished me by the said provider. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services.
SECONDARY INSURANCE INFORMATION:
To continue Physical Therapy beyond 30 days, Medicare now requires that you return to your doctor within 30 days of your last dated prescription to determine medical necessity for treatment. Medicare may deny benefits for Physical Therapy if found without documented cause from your doctor. Therefore you are advised to return to your doctor within each 30-day period of Physical Therapy treatments.
****If you are receiving any HOME CARE services from an agency (i.e. Home Health Aide, visiting nurse, etc.) Medicare will not cover any services at our facility. Medicare stipulates that any patient who is receiving such services must receive all services through that agency. Please inform the front desk if you are currently receiving or plan to receive any HOME CARE services. Any claims denied for this reason will be your responsibility as you have been informed prior to treatment that this is not allowed by Medicare.
If you have any questions please do not hesitate to ask any of our office staff or contact your Medicare representative.
I have read the information above regarding my Medicare benefits and understand what my responsibility is as the beneficiary/patient.
I also authorize this office to release any reports/findings to my referring physician.
I HEREBY STATE THAT THE INJURY IN WHICH I AM RECEIVING TREATMENT FOR IS NOT DUE TO A NO FAULT ACCIDENT OR WORKMAN'S COMPENSATION CASE.
OUR OFFICE IS HIPAA COMPLIANT. ANY QUESTIONS REGARDING OUR POLICIES PLEASE ASK THE FRONT DESK STAFF. *Assignment & Provider Notice Adopted from Medicare Approved Provider Information
Any employee found violating this policy will be reprimanded up to and/or including termination of employment. Violation of a patient’s privacy if found guilty will be subject to civil liability and/or criminal penalties. We are required to report any employee found violating this policy to the Department of Civil Rights. Penalties are as follows: Civil Federal criminal penalties are $100 per violation, up to $25,000 per person per year each requirement of prohibition violated. Federal criminal penalties are up to $50,000 and one year in prison for obtaining protected health information; up to $100,000 and up to five years in prison for obtaining or disclosing protected health information under “false pretenses”; and up to $250,000 and up to 10 years in prison for obtaining or disclosing protected health information with intent to sell, transfer or use it for commercial advantage, personal gain and malicious harm.
Staff members such as PT Aides, front desk staff and Therapists all have access to patient charts for the following reasons; to treat the patient, to set up for a patients treatment plan, request authorization, as well as follow up on claims for payment due at our office, filling out paperwork; maintaining & securing records and communication with the insurance companies and governmental agencies. This will be done on a discrete manner with as little incidental disclosure as possible. A patient or their qualified representative has the right to inspect their patient information within 30 days of our office receiving a written request with the patient’s original signature or qualified representative’s original signature. Copies of the patients chart maybe furnished to the patient at a charge of $75/per page. A patient’s chart may not be copied or reviewed by third party without written authorization from the patient or a qualified representative. This request may be written within 30 days of the patient’s/representative’s dated signature. Copies will not be released with a Photostat copy of the patient’s/representative’s signature unless the authorization states otherwise. A patient or their qualified representative may challenge the accuracy of their information and may require their own brief statement be inserted as a permanent part of their patient information and released whenever the information is released. This individual’s right only pertains to factual statements and not to a provider’s observations, inferences or conclusions. You have the right to receive an accounting of disclosures of protected health information. Patients have the right to make restriction or transfers of their protected health information at any time.
III. Insurance Companies
A patients progress notes will only be released to an insurance company when it is necessary to prove medical necessity for additional visits and or payment of claims. When this information is released to such companies only the necessary information will be released. Information that does not support the medical necessity for continued treatment will not be released. This will be determined by the treating providers own discretion. No Fault cases require copies of patient’s progress notes with each claim. When this information is released to such companies only the necessary information will be released. (Workman’s Compensation cases are excluded from the HIPAA privacy policies.)
The US Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue
Washington, D.C. 20201
William J. Schwarz, P.T., P.C
5700 Merrick Road
Massapequa, NY 11758
HIPAA Release of Information
MEDIA RELEASE AUTHORIZATION FORM
I, hereby authorize The Schwarz Institute of
Physical Therapy and Pro Sports Care of L.I., and its duly authorized employees or agents, to publish the following personal health information / story: (e.g., information relating to the diagnosis, treatment, and health care services provided or to be provided to me and which identifies my name and other personally identifiable information) to be used in print media, on the radio, TV, the OSC website, blog and on the following social media platforms: Facebook, Twitter, Pinterest, and You Tube.
The following information about me will not be disclosed:
I understand that any personal health information or other information released via the social media platform(s) above may be subject to re-disclosure by such social media platform(s) and may no longer be protected by applicable Federal and State privacy laws.
This authorization is valid from the date of my/my representative's signature.
I understand that I have a right to revoke this authorization by providing written notice to the Schwarz
Institute of Physical Therapy and Pro Sports Care of L.I.
However, this authorization may not be revoked if The Schwarz Institute of Physical Therapy and Pro
Sports Care of L.I., its employees or agents have taken action on this authorization prior to receiving
my written notice. I also understand that I have a right to have a copy of this authorization. I further
understand that this authorization is voluntary and that I may refuse to sign this authorization. My
refusal to sign will not affect my eligibility for benefits or enrollment or payment for or coverage