LA MESA REHAB NEW PATIENT INTAKE

LA MESA REHAB NEW PATIENT INTAKE

Form CI-3B: Patient Questionnaire

Front body outline
Front
Back body outline
Back

Medical History

Do you have, or have you had, any of the following diseases or problems?

PATIENT INFORMED CONSENT

I hereby indicate my wish to be a participant in the rehabilitation program offered by La Mesa Rehab.

I understand that the purpose of this program is to enhance my recovery from an injury or illness. I further understand that there exists the possibility that certain changes may occur during treatment. I verify that my participation is fully voluntary and that no coercion of any sort has been used to obtain my participation and that I may withdraw from treatment at any time. I understand that the facility administrator maintains an open-door policy and encourages patients to participate in their health care. I understand that myself, my family, or friends that I authorize, have the ability to attend Patient Care Conferences on the first day of the month in January, March, May, July, September, and November or by request, for purposes pertaining to treatment and progress of patients currently receiving services.

Assignment and release: I hereby assign my insurance benefits to be paid directly to La Mesa Rehab. I understand that I am financially responsible for any non-covered services. I also authorize the facility to release any information required to process this claim.

I have read and fully understand the above information. I state that I am not receiving Home Health Services at this time. Failure to report services to your home will result in LMR not being reimbursed for your treatment. By signing this you assume all financial responsibility of not reporting home health services.

No Show Policy (Required)

La Mesa rehab has a "no show" policy for all of our patients. While we understand that things can happen in life that may conflict with your schedule, we are always just a phone call away to let us know if you need to cancel. Should you have an emergency or require a trip to the ER, we will certainly understand. But the vast majority of no-shows do not involve emergencies. For this reason, La mesa rehab reserves a right to charge you $50 for any no-show appointments where you do not call our office at least 24 hours in advance to cancel or reschedule prior to your treatment day.

By signing this notice you acknowledge that you have been made aware of our no-show policy and that you will receive a bill for no-show appointments

Thank you for your understanding and consideration for our wonderful therapy staff

Patient HIPAA Rights

Consent to the use and disclosure of health information for treatment payment or healthcare operations

I understand that as a part of my healthcare this organization originates, and maintains health records describing my health history, symptoms, examination, test results, diagnosis, treatment, and any plans for future care treatment. I have been made aware of and have access to review or receive a copy of the organization's policies for privacy practices for Protected Health Information (PHI) under HIPAA.

I understand that this information serves as:
● A source of Information for applying my diagnosis and surgical information to my bill.
● A means by which a 3rd party payer can verify that services billed were actually provided.
● A tool for routine healthcare options such as assessing care quality and reviewing the competence of healthcare professionals.

I understand that I have the right:
● To object to the use of my health information for directory purposes.
● To request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations. The organization is not required to agree to the restrictions request.
● To revoke this consent in writing except to the extent that the organization has already taken action in action in reliance thereon.
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