New Patient Portal - Basha Physical Therapy

Patient Information

Patient Name

First

Last

Gender

Female
Male
They

Date of Birth

Reason for Referral

BPT Therapist Name/ Type of Therapy

Diagnosis

Has your child received therapy before?

Yes
No

If so, for what reason?

Name of the therapist/company

Primary Physician (if none please type NONE) *

Phone/fax

Referring Physician

Phone/Fax

DDD Support Coordinator

Phone/Fax

Family Information

Mother or Guardian Information

Mother's Name (or Guardian's Name)

First

Last

Birth Mother
Adoptive Mother
Step-Mother
Guardian

Mother's Birth Date

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Email

Father or Guardian Information

Father's Name (or Guardian's Name)

First

Last

Birth Father
Adoptive Father
Step-Father
Guardian

Father's Birth Date

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Email

Siblings

Name

First

Last

Age

Name

First

Last

Age

Name

First

Last

Age

Insurance Information

Primary Insurance

Company Name

Type of Insurance Co.

ID#

Subscriber's Name/ID

Subscriber's Date of Birth

Subscriber's Social Security Number

Relationship to Patient

Subscriber's Employer

Group/Policy Number

Policy Effective Date

Customer Service Number (on back of card)

Photo: Insurance card front and back

Click or drag files to this area to upload. You can upload up to 2 files.

Special Notes

Insurance Information (continued)

Secondary Insurance

You may skip this page if you don't have secondary insurance.

Insurance Company Name

Type of Insurance Company

ID Number

Claims Mailing Address (found on back of insurance card)

Subscriber's Name/ID

Subscriber's Date of Birth

Subscriber's Social Security Number

Relationship to Patient

Subscriber's Employer

Group Policy Number

Policy Effective Date

Customer Service Number (on back of card)

Special Notes

Developmental History

Birth History/Pregnancy

Full Term?

Yes
No

How many weeks?

Any Complications?

Birth Weight

Delivery

Normal
Breech
C-Section

Early Development

Please list ages of any relevant milestones.

Sitting Unsupported

Example: 5 years, 3 months

Crawling

Example: 5 years, 3 months

Walking

Example: 5 years, 3 months

First Words

Example: 5 years, 3 months

Toilet Trained

Example: 5 years, 3 months

Is your child taking medication?

Yes
No

Has your child ever been diagnosed with any of the following?

Feeding Difficulties

Yes
No

Vision/Hearing Difficulties

Yes
No

Lack of Oxygen

Yes
No

Head Injury

Yes
No

Seizure

Yes
No

Coma

Yes
No

Surgeries

Yes
No

Allergy

Yes
No

Orthopedic Limitations

Yes
No

Please Note Important Details

BPT Financial Policies

Basha Physical Therapy, LLC (BPT) is committed to providing ethical, compassionate care to every patient and their family, in order to do so, it is important to acknowledge your understanding of our financial policy. Please do not hesitate to contact us with any questions regarding fees, financial obligations or policies.

BPT requests a photocopy of your insurance card as well as current driver’s license. Please update your card with our office manager with any changes or new information. It is your responsibility as the patient to inform BPT with any changes to your policy. We bill your insurance company on your behalf as a courtesy.

Please initial each section and sign below.

Co-payment/Co-insurance

We must collect your co-pay at the time of service. Refusal to abide by this agreement may result in termination of your coverage BPT will calculate an estimated copay based on your insurance policy. This amount will be due at the time of each appointment.

Initial Co-payment/Co-insurance *

Clear Signature

Missed Appointments

BPT requests that when possible, more than 24 hours is required for canceling an appointment. If there is a no show or cancellation less than 24 hours in advance, we reserve the right to charge a $35.00 fee for no-show or same day cancellations.

Initial Missed Appointments *

Clear Signature

Returned Checks

If a check is used as a form of payment, and that check is returned secondary to insufficient funds or because payment was stopped, you will be charged a $35.00 fee in addition to the amount of the check.

Initial Returned Checks *

Clear Signature

Insurance

BPT will bill and accept payment from your health insurance plan. Any amount not covered by your insurance carrier is your responsibility. Communication between BPT and it’s patients is imperative, please advise us immediately if your insurance has changed, or if there are known pre-certification/prior authorization requirements.

Initial Insurance *

Clear Signature

Payments

You are responsible for any amount not covered by your insurance carrier. All co-pays and deductible amounts are due at time of service. BPT accepts checks, money-orders and cash. I have read and understand BPT’s financial policies. I hereby authorize Basha Physical Therapy, LLC to submit claims to my insurance carrier. I hereby authorize direct payment of benefits, otherwise payable to me, to be made payable to Basha Physical Therapy, LLC. I understand I will be responsible for payment of any amounts not covered by my insurance carrier, including but not limited to copays and deductibles.

Initial Payments *

Clear Signature

I have read and understand the above policies.

Print Parent or Guardian Name *

Signature *

Clear Signature

Date *

BPT Business Policies

Please initial each section and sign below.

Cancelation/No Show Policy

Your therapist will create a individual, specialized plan of care for your child based on the families goals as well as the needs of your child. Attendance at your scheduled appointments is essential for the success of your child in therapy. Failure to abide by this plan could result in discharge of therapy services from BPT. The following (but not limited to) could warrant discharge:

*Your child fails to show (misses) 2 consecutive appointments without any contact with our office or your therapist via phone. Failure to call to cancel your appointment at least 2 hours prior to your scheduled appointment time is considered a no show. Please feel free to leave a message if it is after hours.

*Your child cancels 3 different appointments within one quarter (severe illness/injury or hospitalization are exceptions.) If you are aware you will be missing 2 or more consecutive visits, please let you therapist know ahead of time. Unfortunately we will not be able to hold your appointment slot for any time longer than 3 weeks of absences.

Initial Cancelation/No Show Policy *

Clear Signature

Discharge Policy

As mentioned above, your therapist will create an individual, specialized plan of care for your child. This includes discharge planning. The following conditions (but not limited to) could result in discharge of therapy from BPT.

*Plateau in function in relation to established goals. BPT’s therapists treat patients with a realistic, functional goal related mentality. Goals are based on medical needs as well as family/community related goals. If it is under the skilled therapist’s opinion that the patient is no longer making progress towards these goals, discharge is possible. General rule of thumb is if your child has not progressed on any goals over 2 quarters, discharge will benefit the child.

*Meeting all established goals. On the occasion when your child meets all of her established goals and the therapist has deemed skilled services are no longer medically necessary, the patient will be discharged from BPT.

Initial Discharge Policy *

Clear Signature

I have read and understand the above policies.

Print Parent or Guardian Name *

Signature *

Clear Signature

Date *

Authorization for Release of Medical Records

Please enter required information and sign below.

I hereby authorize Basha Physical Therapy, LLC to release the medical record(s) of:

Patient Name

Date of Birth

for the purpose of continued treatment, healthcare operations, and billing/reassignment of benefits (allows BPT to bill on your behalf, and for the payment to be sent directly to BPT) to:

Basha Physical Therapy, LLC
PO Box 267
Queen Creek, AZ 85142
Phone: 480-848-4281
Fax: 480-393-7040

Records Release: I acknowledge BPT to send requested/pertinent information regarding my child,

Child's Name

and their therapy services to any person/professional listed below. This also authorizes BPT to request records from any person/professional when appropriate. I understand this will only occur when required for continuity of care.

Type of Provider/Name, and Phone Number

Please enter the information separated by commas and each on a new line. Example: Pediatrician, Dr. Jones, 555-432-1234

I have read and understand the above policies.

Print Parent or Guardian Name *

Signature *

Clear Signature

Date *

Notice of Privacy Practices

Please read and sign below.

Your name and signature below indicate that you have received a copy of and/or have been directed to the Notice of Privacy Practices by Basha Physical Therapy, LLC on the the date listed below. If you have any questions regarding the information, please do not hesitate to contact Basha Physical Therapy, LLC directly.

*I understand there is a Notice of Privacy Practices available for me, at any time-if requested from my therapist.

*I understand I have the right to: advise Basha Physical Therapy, LLC if I do not want messages left at the numbers I have provided regarding medical treatment, appointments or billing

Print Parent or Guardian Name *

Signature *

Clear Signature

Date *

Photo/Video Release

Please enter information and sign below.

I (name of Parent or Guardian)

authorize Basha Physical Therapy, LLC the use of photos and/or videos for purposes of therapy/therapy related services including but not limited to online/paper marketing, other publications, therapy related learning/assessment for my child,

Child's Name

I understand these media items will not be shared or published for any purposes other than what is stated by Basha Physical Therapy, LLC. I release Basha Physical Therapy, LLC, it’s employees and contractors from liability in connection with my/my child’s media participation.

I have read and understand the above policies.

Print Parent or Guardian Name

Signature *

Clear Signature

Date *