PHYSICAL THERAPY SOUTH, INC

Patient Registration

Personal Information
Primary Insurance Information
If “Yes”, list claim # and adjustor contact information below:
Secondary Insurance Information

Consent for Treatment

I hereby authorize PHYSICAL THERAPY SOUTH, INC and its employees to render therapy in accordance with my physician’s orders or direct access and accepted standards of practice for physical, occupational or speech therapy.  I consent to abide by the established plan of care determined by the therapist including termination of therapy services at my request, physician’s request and/or the request of PHYSICAL THERAPY SOUTH, INC.

Assignment and Instruction for Direct Payment to Health Provider

I hereby instruct the above named insurance company/companies to pay by check/virtual credit card made out to and mailed directly to:  PHYSICAL THERAPY SOUTH, INC for professional/medical expenses allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for services rendered.

THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY.

This payment will not exceed my indebtedness to the above mentioned assignee and I agree to pay, in a current manner, any balance of said professional fees for non-covered services and/or fees, over and above the insurance payment as required by my insurance policy.

Patient Financial Responsibility 

PHYSICAL THERAPY SOUTH, INC appreciates the confidence you have shown in choosing us to provide you with therapy services.  The services you have elected to participate in implies a financial responsibility on your part.  The responsibility obligates you to ensure payment in full of our fees.  As a courtesy, we will verify your coverage and bill your insurance carrier.  However, you are ultimately responsible for payment of your bill. 

You are responsible for payment of any deductible and co-payment/co-insurance as determined by your contract with your insurance carrier.  Our staff will provide you with an estimate of your cost for each date of service visit.  We expect these payments to be made at the time of service and recommend you leave a credit/debit/HSA card on file with our office.  

In the event our staff does not collect the full amount due by you at the time of service, you will receive a statement in the mail.  You are responsible for payment upon receipt of the statement or for contacting our billing company to set up an acceptable payment plan.  

I have read, understand, and agree to the provisions of this Patient Financial Responsibility.

Medical History Information

2. Do you now or have you ever had the following?

Orthopaedic History/Other – Please give dates & treatments received:

  1. Have you ever sprained, strained, dislocated or fractured the following:

NOTICE OF PRIVACY RIGHTS

PHYSICAL THERAPY SOUTH, INC 

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.

  1. Below is a description, including at least one example, of the types of uses and disclosures that the above organization is permitted to make for each of the following purposes: treatment, payment and health care operations.
  2. Disclosures to other health care providers, including, for example, to patients’ attending physicians.  Disclosures to conduct the operations of the organization, including, for example, sharing information to supervisors of staff members who provide care to patients.
  1. Below is a description of each of the other purposes for which the organization is permitted or required to use or disclose protected health information without an individual’s written consent or authorization.
  2. To patients, incident to another permitted use or disclosure, by agreement, to the Secretary of the U.S. Department of Health and Human Services, as required by law, for public health activities, information about victims of abuse, neglect or domestic violence, health oversight activities, for judicial and administrative proceedings, for law enforcement proceedings, about decedents, for specific government functions, to business associates of the organization, to personal representatives, de-identified information, to workforce members who are victims of crimes, to workers’ compensation programs, for  involvement in the individual’s care and for notification purposes, with the individual present, for limited uses and disclosures when the individual is not present, and for disaster relief purposes.   
  1. Other uses and disclosures, such as use of protected health information for marketing activities will only be made with the individual’s written authorization.
  2. The organization may contact the individual to schedule visits and for other coordination of care activities.
  3. The individual has the right to receive confidential communications of protected health information, the right to inspect and copy protected health information, the right to amend protected health information, the right to receive an accounting of disclosures of protected health information and the right to obtain a paper copy of these privacy rights.
  4. The organization is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected health information and to notify affected individuals following a breach of unsecured protected health information.
  5. The organization is required to abide by the terms of this Notice currently in effect.
  6. For further information, individuals should contact Vickie D. Cavitt, Privacy Officer at the following telephone number:  337.232.2444 or by email at vickie@rehabilling.com

Notice of Privacy Practices

I hereby authorize that I am aware of my rights as it pertains to HIPAA and my Protected Health Information (PHI).  PHYSICAL THERAPY SOUTH, INC has offered me a copy of their Notice of Privacy Practices for my own records.

If there is anyone you would like to authorize the disclosure of your PHI, medical or billing, you may specifically name the party below and indicate what information you would like disclosed:

Contact Us

For security reasons, we ask that you please do not transmit any sensitive patient data over the website contact form. Let us know a time and phone number that we can reach you.

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