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Welcome to OSR Physical Therapy.

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Date _________________________________________
Patient Name __________________________________
Address ______________________________________
City/State/Zip _________________________________
Home Phone __________________________________
Work Phone ___________________________________
Cell Phone ____________________________________
Email Address _________________________________
Social Security Number __________________________
Sex:
Male
Female
Age
____ Date of Birth __________________________
Referring Physician(s) ____________________________________
Date of last Doctor Visit __________________________________
Date of next Doctor Visit _________________________________
Date of Onset __________________________________________
Related to Accident?
Work
Auto
Other
N/A
Employed:
Full-Time
Part-Time
Retired
Not working
Employer
_____________________________________________
Employer Address ______________________________________
Marital Status:
Single
Married
Other
Student: Full-time Part-Time Not a Student
How did you hear about OSR?
Doctor
____________________
OSR Staff
_____________
Other
_____________________
Family/Friend
Email
Mailer
Internet
Insurance
Patient Information
Responsible Party
Name ________________________________________
Address ______________________________________
City/State/Zip _________________________________
Home Phone __________________________________
Work Phone ___________________________________
Employer Name ________________________________
Employer Address ______________________________
City/State/Zip _________________________________
Name of Insurance Company _____________________________
Insurance Co Phone Number _____________________________
Insurance Co Address ___________________________________
Name of Insured _______________________________________
Insured’s Address _______________________________________
Insured’s Phone ________________________________________
Sex: Male Female Date Of Birth (mm/dd/yy) _____________
Social Security Number __________________________________
Relationship to Insured:
Self
Spouse
Child
ID Number
____________________________________________
Group Number ________________________________________
Insurance Information
Emergency Contact Information
(Last Name, First Name, Middle Initial)
(Last Name, First Name, Middle Initial)
Relative/Friend _________________________________________
Home Phone ______________________________________
Phone _______________________________________
Welcome to OSR Physical Therapy.
Please fill out this form completely. Thank You!
Relative/Friend _________________________________
Home Phone ______________________________
Phone _______________________________
OSRPhysicalTherapy.com
Cell
Cell
Patient’s Age __________________________________________
Patient Occupation _____________________________________
When did the pain start? _________________________________
X-rays
CT scan
EMG/NCV
MRI
Arthrogram
Injections
Date _________________________________________
Patient Name __________________________________
(Approximate Date)
Patient Information
Health History
How did the pain start?
Suddenly
Gradually
Lifting
No apparent reason
Pulling
Injured at work
Bending
Other
What activities make the pain worse?
Exercise (during)
Exercise (after)
Sitting
Walking
Bending forward
Bending backwards
Coughing
Sneezing
What reduces the pain?
Lying down
Sitting
Standing
Walking
Anti-inflammatories
Pain pills
Injection for pain
Muscle relaxants
Nothing
Other
How long have you had this pain?
_____Years
_____ Months ______ Weeks
_____Years
_____ Months ______ Weeks
How long have you had similar pain?
Have you had any of these diagnostic tests?
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Date
_______________
Date _______________
Date _______________
Date _______________
Date _______________
Date _______________
Have you been hospitalized for your problem?
Yes
No Date: _______________________
Have you had surgery for your problem?
Yes
No Date: _______________________
Have you had any other surgery performed?
Yes
No Date: _______________________
Pain/Symptoms
On the Body Diagram to the right,
indicate your region of pain using
the symbols below:
What medications are you currently taking?
_____________________________________________________
Yes/No
Allergies
Diabetes
High blood pressure
Heart disease
Stroke (CVA)
Cancer or tumors
Lung problems
Arthritis-joint difficulties
(Ir)regular headaches
Dizziness-blackouts
Seizures-nerve disorders
Visual problems
Menstrual problems
Immunity disorders
Gout
Are you pregnant?
Joint replacement
Night sleep disturbance
Change in bowel or bladder habits
Change in stool color or rectal bleeding
Increased thirst or hunger
Frequent urination
Indigestion or heartburn
Nausea or vomiting
Changes in memory
Unusual fatigue-weakness
Fever or chills
Frequent or easy bruising or bleeding
Frequent cramping
Do you have pain 24 hrs?
Do you awaken from pain?
Do you smoke? ______ #/Day
Do you drink? _______ #/Day
Yes/No
What other types of doctor/health care providers have you seen for
this condition?
___________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
(X) Sharp
(+) Numb/Tingling
(#) Dull/Aching
(B) Burning
Pain Level
(0-10)
Patient Health History
Please fill out this form completely. Thank You!
OSRPhysicalTherapy.com
We are dedicated to providing the best possible care and service to you and regard your complete understanding of our financial
policies as an essential element of your care and treatment. If you have any questions, please discuss them with us prior to beginning
therapy.
Financial Policy, Release of Information, Assignment of Benefits
Your insurance policy is a contract between you and your
insurance company. As a courtesy, we will file your
insurance claim for you if you assign the benefits to us.
In other words, you agree to have your insurance
company pay us directly. If your insurance company does not
pay us within a reasonable time period, we will have to look to
you for payment of the outstanding balance.
We have made prior arrangements with many insurers and
other health plans to accept an assignment of benefits. We
will bill those plans with which we have an agreement and
will only require you to pay the copayment at the time of
service.
If you have a copay, you may either pay each time you come
for your appointment or you may pay in advance to cover all
visits for the week. Once the insurance company has begun
to process our bills, if there is a balance due, we will send
you a statement each month for the amount you owe – i.e.
deductible, coinsurance, copay, until all claims have been
processed. Payment is due upon receipt of our bill.
If you have insurance coverage with a plan with which we do
not have a prior agreement, we will prepare and send the claim
for you on an unassigned basis. This means your insurer will send
the payment directly to you. Therefore, all charges for your care
and treatment are due at the time of service.
Unless other arrangements have been made in advance by you,
or your health insurance carrier, payment for services are due at
the time of service.
All health plans are not the same and do not cover the same
services. We will do our best to determine what services
are covered by your insurance and let you know if there
is a recommended treatment that is not a benefit of your
insurance so that you may decide to proceed with the
treatment or elect not to have the treatment performed.
In the event your health plan determines a service to be
“not covered” and we are unaware or you do not have
authorization, you will be responsible for the complete
charge.
You must inform our office of all insurance changes and
authorization referral requirements. In the event the office is not
informed, you will be responsible for any charges that are denied.
For all services rendered to minor patients, we will look to the
adult accompanying the patient and the parent or guardian for
payment.
Payments and Patient Signature
Past due accounts are subject to collection proceedings. All fees
including, but not limited to collection fees, attorney fees, and
court fees shall become your responsibility in addition to the
balance due this office.
Patient accounts carrying a balance longer than 30 days are subject
to a minimum monthly payment of $75 or 25% of the outstanding
balance due, whichever is larger.
There is a $50.00 service fee for all returned checks.
Fees Policy
A $30.00 fee will be charged for all “No Shows”.
Cancellations without a 24-hour notice will be assessed a $15 Fee.
These fees are not reimbursable by insurance and are considered
due at your next visit..
I have read and understand the financial policy of OSR
Physical Therapy and I agree to be bound by its terms. I also
understand that such terms may be amended from time to
time by this office.
I authorize the release of information necessary for treatment,
payment & health care operations.
I also authorize assignment of benefits for services rendered
by OSR Physical Therapy.
Patient/Responsible Party Signature
______________________________________________
Date
__________________________________________
OSRPhysicalTherapy.com
Medical Assignment of Benefits and Financial Policy
Please read this document in its entirety
I have read and understand the OSR Physical Therapy Notice of Privacy Practices containing a more complete description of the
uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy
Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of
the Notice of Privacy Practices.
Patient Name
______________________________________________________________________
Relationship to Patient ______________________________________________________________
Signature ________________________________________________________________________
Date ____________________________________________________________________________
Patient Information and Signature
Please Carefully Review the OSR Physical Therapy Notice of Privacy Practices Booklet Prior to Signing Below
Office Use Only
I attempted to obtain the patient’s signature in acknowledgement of this Notice of Privacy Practices
Acknowledgement, but was unable to do so as documented below:
Date Initials Reason
Please contact us for more information:
OSR Physical Therapy
41125 N. Daisy Mountain Dr., Suite 121
Anthem, AZ 85086
623-551-9706
For more information about HIPAA or to file a complaint:
The US Department of Health & Human Services
Office of Civil Rights
200 Independence Ave SW
Washington, DC 20201
Toll Free: 1-877-696-6775
OSRPhysicalTherapy.com
Privacy Practices
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Completed 23 March 2021

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