OFFICE IN SCREENING
Do you have any of the following?
PATIENT INFORMATION
EMERGENCY INFORMATION
In case of an emergency who should be notified?
Patient Initial Intake Form
How severe is the pain (0=none, 10=severe pain)
Please list your medications, dose and frequency (please include any vitamins or over the counter medications)
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:
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
The US Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue
Washington, D.C. 20201
Privacy Officer
William J. Schwarz, P.T., P.C
5700 Merrick Road
Massapequa, NY 11758