Patient Sign-in

Patient Registration Form

Patient Sign-in
New patient Registration
Medical History
Medical history
Your Privacy : Information transmitted from this page is encrypted and secure. Your data will never be used by anyone other than your healthcare provider.

Patient Registration( * mandatory to fill )

Please Select Type Of Registration
Adult
Child

Adult Patient Registration( * mandatory to fill )

Employment Information

Are you a Student?
Yes
No

Student Information

Student Status:
Full Time    Part Time

Spouse Information

Parent/Guardian Information

Child Registration

Adult Medical History

Do you presently have any heart condition?
Yes
No
Have you ever been diagnosed with the following conditions? Please check all that apply:
Have you had any surgeries?
Yes
No
Have you had therapy previously for the same problem?
Yes
No
Are you receiving other treatment for this problem at this time?
Yes
No



 MRI
 X-Ray
 CT Scan
 Swallow-study
 Cognitive Assessment
 Other
Concerns

Please list any medications you are currently prescribed: (Press + sign to add your medication)

+   -

PAIN

Do you have pain now?
Yes
No
Yes No

Rate your pain on a scale of 0-10 (0 Being No Pain and 10 being Worst Pain)

AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION

Designated individuals may include relatives, family members, decedents, friends and/or personal representatives (such as lawyers, accountants, secretaries, or person who holds power of attorney) who a patient authorizes to receive protected health information.

Authorized Individuals

CONSENT FOR TREATMENT

The undersigned gives Care First Rehab consent to evaluate and treat this patient as necessary and advisable.

(Please click below to draw/upload sign)
(Your IP Address : )

Availability

Does your child goes to school ?
Yes
No
Please check the appointment availability:

APPOINTMENT CANCELLATIONS & NO-SHOW POLICY

Cancellations

Must Notify Care First Rehab 24-hours in Advance for both Clinic and On Location patients

To better serve all our patients, if you miss 3 appointments without calling 24 hours prior to the appointment you may be released from practice. This is not intended to cause any inconvenience to you, but to make these appointments available to patients who need appointments.

Contact Us Right Away to Avoid Cancellation/No-Show Fees

Patient will be charged a $25 Fee for Missed/No-Show Appointments.
Fee is patient’s responsibility and is NOT billed to any insurance carriers.
Cancellation/No Show Fee does not apply to Medicare, Medicaid and CDSA patients.

Care First Rehab understands that on occasion emergency situations may occur that prevent 24-hour notice. Inclement weather is one such situation. These cases will be handled on an individual basis at the discretion of the treating therapist and/or the office manager.

An appointment is also considered a “No Show” if you do not arrive on time for your scheduled appointment and thus the therapist is unable to see you.

Workers Compensation Patients Only

Advance Notice of 48-hours is required; Your case manager and/or insurance carrier routinely follows up with your treatment and will be notified of cancelled or no-show appointments.

Yes, I acknowledge and understand the Cancellation/No-Show of Care First Rehab.
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

FINANCIAL POLICY

Thank You for Choosing Care First Rehab
Please carefully review our financial policy. It is important for you to have a thorough understanding of your benefits and responsibilities. Care First Rehab (CFR) Financial Policy is applicable for all patients (clinic and on- location.)

We Gladly Accept:

  • Cash
  • Checks
  • Money Orders
  • VISA / MasterCard / Discover / American Express

Make Payments:

  • Online at www.carefirstpt.com via patient portal
  • Over the phone at: 919.460.1921
  • On-site in our clinic
  • via Mail

Payment-in-Full is Due at Time of Services Rendered

  • Co-Pays and coinsurance amounts, deductibles, and all non-covered items and charges are the insured/patient’s financial responsibility and are due during the Check-In process. Failure to produce payment at Check-In may result in your appointment being rescheduled.
  • If you receive more than 1 type of service on the same day, you may be responsible for more than one Co-Pay.
  • Any amount not covered by the insured/patient’s insurance is due within 30-days of the time of service.
  • Any outstanding balance may incur a $10 monthly statement processing fee, in addition to the initial balance.
  • Failure to pay balances (up to 3 visits); Care First Rehab will “Stop Services” until we receive payment; If no payment is received, we will discharge the patient from CFR.

Missed or Cancelled Appointments | Other Fees

  • Patient must provide 24-hour notice to cancel and/or reschedule all appointments. Failure to do so will result in a $25 “No-Show” fee.
  • All Co-Pays are due at the time of service. Any Co-Pay not received at time of service will result in a $15 processing fee. If Co-Pay is received within 7-days of the date of service, the $15 processing fee will be waived.
  • Checks: $30 fee for NSF (Non-Sufficient Funds).
  • All balances are due prior to any further service provided by our office.
  • Missed and Cancellation fee does not apply to Medicare, Medicaid and CDSA patients.

Credit Card On-File Policy

  • Effective September 1, 2017, Care First Rehab requires that a credit card be on-file for all home-care (on-location) patients. Our therapists are not allowed to accept or process any payments. Please call our office at 919-460-1921 to set-up your account and to answer any questions.
  • DO NOT give any credit card information to your therapist. Patient must contact Front Office at 919-460-1921.

No Insurance | Self-Pay Patients

  • Patient will be responsible for all fees/services.
  • Care First Rehab requires that a credit card be on-file.

In-Network vs Out-of- Network Insurance

  • Your insurance coverage and benefits are a contract between you and your insurance company, therefore all disputes must be handled between you and your insurance company.
  • If we are out-of- network with your insurance provider, you will be treated as a self-pay patient.
  • Verify insurance benefits requires a 48-hour notice
  • We are required to file with your primary insurance carrier only. It is your responsibility to file charges with any secondary insurance carriers for reimbursement.
  • All charges are your responsibility whether your insurance company pays or does not pay. Not all services are a covered benefit in all contracts. Some insurance companies and some employers decide what is a covered benefit and what is not. Please check your insurance plan document for any questions. Fees for these services along with unmet deductibles and co-payments are due at the time of treatment.

Medicare | Medicaid

  • Medicare. Care First Rehab is a participating provider with the Medicare program and accepts as payment the Medicare allowable, patient deductible and/or 20% co-insurance. Medicare or secondary carriers do not cover some procedures and supplies. Please make certain you understand which aspects of your treatment are covered before proceeding. You understand that you will be responsible for your annual deductible, the co-payment, and any non-covered services specified by Medicare. We may submit a claim to any supplemental plan as a courtesy to you, so long as you provide all necessary policy information.
  • Medicare requires that we provide patients with a written notification whenever it is likely that you will be responsible for a bill.
  • Pending Medicaid – we do not retroactively bill Medicaid for services performed prior to the date of initial eligibility verification. If you have no insurance coverage, you will be considered a self pay patient and will be responsible for all services that you received prior to the initial eligibility date.

Minor Patients

  • Parents or guardians accompanying a minor are responsible for providing current insurance information for the minor as well as the payment-in-full for services provided.
  • In compliance with HIPAA regulations, we are unable to discuss any details of services rendered or to produce an itemized bill for any parties that are not the parent or guardian, unless otherwise documented.
  • Both parents/legal guardians are responsible for payment for services rendered to the minor patient. A copy of this financial policy and all statements will be provided to each parent if living in separate residences.

Auto Accidents | Workers’ Compensation

  • Motor Vehicle Accidents will be filed to your auto insurance as a courtesy to you. Failure to receive payment within 30-days of the date of service may result in your responsibility to pay.
  • Our office will send appropriate Workers’ Compensation claim forms for services rendered on your behalf as a courtesy. If a claim is denied, we will expect payment-in-full from you within 30-days of receipt of our bill (a good faith deposit of 25% is required for longer term of repayment.)
  • Six Month Case Settlement Policy: We will wait for settlement of your claim for up to six months after your care is completed. After the six month mark, patients will be directly responsible for their medical bills. Arrangements can be made to pay the balance.

Payment Plans

  • Please contact our Billing Department to work out a payment plan
  • Mail payments 5-days prior to due date
  • Make Payments Via: Mail, Phone or Online
  • We accept CareCredit, a healthcare credit card that provides 6-months, interest free financing. Visit CareCredit.com to apply online and for further details.

Collections & Outstanding Balances

  • The provider reserves the right to add a $10 monthly statement processing fee on any account that has an unpaid balance.
  • Any outstanding balance after 75-days, from the time of service, may be referred to an outside collection agency. Accounts referred to a collection agency or attorney may be subject to a collection fee of 25%, which will be added to the total balance due at the time of write-off.
  • Patients with unpaid delinquent accounts or accounts sent to collection agency will be discharged from our practice. All services will be stopped.

Refunds

  • Refunds are issued to the appropriate party
  • Patient refunds will not be processed until all active or past due charges are paid-in-full.
  • Refunds less than $10.00 will not be issued, unless otherwise requested; we will credit your account with Care First Rehab. Patients will be notified of this.

Additional Paperwork

  • Any additional paperwork needed to be filled-out by the therapist will result in either a $5 or $10 charge depending on the length of the paperwork.
  • A 48-hour notice is required for all paperwork requests and processing.

Care First Rehab
100 Cornerstone Drive
Cary, NC 27519
Office: 919-460-1921
Fax: 919-460-1929
Website: www.carefirstpt.com
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )
Yes, I acknowledge and understand the Financial Policy of Care First Rehab.

HIPAA NOTICE

HIPAA

Health Insurance Portability and Accountability Act

Legal Duty

Care First Rehab is required by law to protect the privacy of your personal health information, provide this notice about our information practices and follow the information practices that are described herein.

Uses and Disclosures of Health Information

Care First Rehab uses your personal health information primarily for treatment, obtaining payment for treatment, conducting internal administration and evaluating the quality of care that we provide. Some examples of uses of your personal health information may include, but are not limited to, the following: (1) Contacting you by telephone/mail and leaving a message if necessary to provide or obtain information regarding appointments, your treatment, your patient account, treatment alternatives or other health related benefits and services that we offer, and/or company news; (2) Obtaining information from your referral source in order to schedule an appointment and to verify/authorize insurance benefits, (3) Announcing your arrival to the therapist in an area where others may hear the information, (4) Calling out your name in the waiting area, (5) Placing your encounter form and/or medical record in a slot beside your treatment room door, (6) Treating you in an open area where conversations between you and your therapist may be overheard buy other patients and staff, (7) Sharing information as needed with other health care providers involved in your care, (8) Performing quality assurance tasks such as chart review and outcomes analysis, (9) Forwarding information to your insurance carrier in order to receive payment on claims (after obtaining your Medical Records Release and Insurance Assignments), and/or (10) Sharing information to insurers and other entities involved in your workers’ compensation case as authorized by law.

Care First Rehab may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law.

In any other situation, Care First Rehab’s policy is to obtain your written authorization before disclosing your personal information. If you provide us with a written authorization to release information for any reason you may later revoke that authorization to stop future discloses at any time.

Patient’s Individual Rights

You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes.

You may request in writing that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in an emergency circumstance. Care First Rehab will consider all such requests on a case-by- case basis, but the practice is not legally required to accept them

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

HIPAA NOTICE & FINANCIAL POLICY

The undersigned acknowledges receipt of Care First Rehab’s HIPAA Notice and Financial Policy

(Please click below to draw/upload sign)
(Your IP Address : )
Yes, I acknowledge and understand the Hipaa Notice & Financial Policy of Care First Rehab.

Family History


Does your child have IEP? Yes No N/A

Child Medical History

Pregnancy
Full-term
Premature

Current Medications: (Press + sign to add your medication)

Developmental Milestones
Speech
Achieved within normal limits
Delayed
Gross Motor (rolling, crawling, walking):
Achieved within normal limits
Delayed
Fine Motor(coloring, writing, cutting):
Achieved within normal limits
Delayed

Speech History

How does your child currently communicate?
Gestures/sign language
Sounds
Words
Phrases (2-3 words)
Sentences (4 or more words)
Other
Is English the primary language spoken at home?
Yes
No
Additional Information
Is your child currently enrolled in daycare or school? Yes No

Occupational History/Daily Routine:

Hand preference : Right Handed Left Handed Not Yet Emerged
Meal Time
Is your child a picky eater? Yes No
Please check all utensils your child can uses during feedings:
Please check the type of cup your child can use independently:
Dressing
Can your child dress him/herself?
Yes
No
Can your child manage:
Buttons
Yes
No
Zippers
Yes
No
Snaps
Yes
No
Shoes
Yes
No
Socks
Yes
No
Tie Shoes
Yes
No

Self Help Skills

Can your child independently:
Brush Teeth:
Yes
No
Wash Face:
Yes
No
Bath
Yes
No
Brush/Comb Hair:
Yes
No
Potty Trained:
Yes
No

Social/Play Skills

Does your child become upset or distracted when transition between activities?
Yes
No
Does your child have difficulty with large crowds or loud noises?
Yes
No

Additional Information

Does your child exhibit any concerning behaviors at school?
Yes
No
Has your child had any previous occupational therapy?
Yes
No
Patient Sign-in
Thank you for visiting Care First Rehab. We want your visit to be pleasant and comfortable.Please help us by completing this form
Patient Registration

Adult Personal Details

Title: First Name: Last Name: Middle Initial:
Street Address: City: State: Zip Code:
Gender: DOB: Marital Status:
Last appointment Date with the Primary Physician:
Employer Name:
Address: Home Phone: Cell Phone: Work Phone: Email Address:
Are you a Student? Yes No

Student Information

Student Status? Full Time Part Time
Name of School:

Spouse Information

Spouse Name: Phone#: Spouse Occupation: Employer: Work Number: Emergency Contact Name: Phone#: Relationship:
Please tell us how you heard about us:
Doctor Referral
Insurance Referral
Online
Family/Friend
Other
Please specify, If other?

Adult Medical History

Referring MD: Family MD:
What is your reason for coming to therapy Today?
When/how did your problem begin?
Do you presently have any heart condition?
Yes
No
If yes, Describe
Have you ever been diagnosed with the following conditions? Please check all that apply:
High Blood Pressure
Shortness of Breath
Osteoarthritis
Circulatory Problems
Back or Neck Problems
Stroke
Diabetes
Cancer
Rheumatoid Arthritis
Seizures
Presently Pregnant? Or Possibly Pregnant?
Other
Have you had any surgeries? Yes No
If Yes, please list with Date

Have you had therapy previously for the same problem? Yes No
Are you receiving other treatment for this problem at this time? yes No
If Yes, please list
What kind of tests have been done for your current problem?

MRI
X-Ray
CT Scan
Swallow-study
Cognitive Assessment
Other
If Other, please list:

Concerns

Getting in/out of Bed
Rising from sitting to standing
Walking
Reaching into cabinets (high/low)
Grooming myself/bathing
Speaking Clearly
Written Communication
Memory
Swallowing Difficulty if so list food and/or drinks

Please list any medications you are currently prescribed:

Medication Strength Dosage/How Often? Last Dose?
     

PAIN

Do you have pain now? Yes No
Location/Type:
What makes it better?
What makes it worse?
Does the pain interfere with your daily life? Yes No
Describe

Rate your pain on a scale of 0-10 (0 Being No Pain and 10 being Worst Pain)

Rate your pain

Pediatric History section

Child's Name: Gender: Date Of Birth:
Address: City: Zip Code:
Home Phone: Cell Phone: Guardians’ Email Address:
Last Appointment Date with the Primary Physician:
Are you a Student? Yes No

Student Information

Student Status? Full Time Part Time
Name of School:

Parent/Guardian Information

Parent Name: Phone#: Parent Occupation: Employer: Work Number: Emergency Contact Name: Phone#: Relationship:
Please tell us how you heard about us:
Doctor Referral
Insurance Referral
Online
Family/Friend
Other
Please specify, If other?

Family History

Father’s Name: Date of birth: Occupation:    Mother’s Name:: Date of birth: Occupation:

Siblings

Name:   Age:   Delays:
Name:   Age:   Delays:
Additional Comments:

Current Services

Does your child have IEP? Yes No N/A

Child Medical History

Pregnancy Full-term Premature
Length of Pregnancy(In Weeks)
Unusual Conditions at or immediately after birth:
Please explain any injuries, serious illnesses, or accidents that may have affected your child’s overall development:
Date of last hearing screen
Outcome:
Does your child have a medical diagnosis? Please explain

Current Medications:

Medication Strength Dosage/How Often? Last Dose?
     
Allergies Feeding/Food Issues

Developmental Milestones

Speech Achieved within normal limits Delayed
If delayed, please explain:
Gross Motor (rolling, crawling, walking): Achieved within normal limits Delayed
If delayed, please explain:
Fine Motor(coloring, writing, cutting): Achieved within normal limits Delayed
If delayed, please explain:

Speech History

What are you biggest concerns regarding your child’s speech and language skills?
How does your child currently communicate? Gestures/sign language Sounds Words Phrases (2-3 words) Sentences (4 or more words) Other
Please specify, If other
Is English the primary language spoken at home? Yes No
If no, what is the language?
If no, does your child understand and speak English Language?

Additional Information

Is your child currently enrolled in daycare or school? Yes No
Please list area(s) of difficulty in Preschool/School (i.e. writing, learning, social skills):
Does your child experience difficulty with reading tasks? Please explain:

Occupational History/Daily Routine:

Hand preference : Right Handed Left Handed Not Yet Emerged

Meal Time

Is your child a picky eater? Yes No
Please check all utensils your child can uses during feedings:
Fingers Spoon Fork Knife
Spork
Please check the type of cup your child can use independently:
Bottle Sippy Cup Open Cup Straw
Additional Comments:

Dressing

Can your child dress him/herself? Yes No

Can your child manage

Buttons Yes No
Zippers Yes No
Snaps Yes No
Shoes Yes No
Socks Yes No
Tie Shoes Yes No

Self Help Skills

Can your child independently:

Brush Teeth: Yes No
Wash Face: Yes No
Bath: Yes No
Brush/Comb Hair: Yes No
Potty Trained: Yes No
Any behavioral concerns during routine hygiene tasks?

Social/Play Skills:

Does your child become upset or distracted when transition between activities? Yes No
If yes, please explain:
Does your child have difficulty with large crowds or loud noises? Yes No
If yes, please explain:
Does your child exhibit any concerning behaviors at school? Yes No
If yes, please explain:
Has your child had any previous occupational therapy? Yes No
If yes, please explain:
What are your biggest concerns regarding your child’s occupational skills?

AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION

Designated individuals may include relatives, family members, decedents, friends and/or personal representatives (such as lawyers, accountants, secretaries, or person who holds power of attorney) who a patient authorizes to receive protected health information.

Authorized Individuals

Name:    Relationship:    Phone:   
Name:    Relationship:    Phone:   

CONSENT FOR TREATMENT

The undersigned gives Care First Rehab consent to evaluate and treat this patient as necessary and advisable.

 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
If not Patient, Relationship to Patient

Availability

Does your child goes to school? Yes No
Please check the appointment availability:
9-12 12-3 3-6
Place Of Service:
Home
Other
If other, please specify:
Comment

APPOINTMENT CANCELLATIONS & NO-SHOW POLICY

Cancellations
Must Notify Care First Rehab 24-hours in Advance for both Clinic and On Location patients

To better serve all our patients, if you miss 3 appointments without calling 24 hours prior to the appointment you may be released from practice. This is not intended to cause any inconvenience to you, but to make these appointments available to patients who need appointments.

Contact Us Right Away to Avoid Cancellation/No-Show Fees

Patient will be charged a $25 Fee for Missed/No-Show Appointments.
Fee is patient’s responsibility and is NOT billed to any insurance carriers.
Cancellation/No Show Fee does not apply to Medicare, Medicaid and CDSA patients.

Care First Rehab understands that on occasion emergency situations may occur that prevent 24-hour notice. Inclement weather is one such situation. These cases will be handled on an individual basis at the discretion of the treating therapist and/or the office manager.

An appointment is also considered a “No Show” if you do not arrive on time for your scheduled appointment and thus the therapist is unable to see you.

Workers Compensation Patients Only

Advance Notice of 48-hours is required; Your case manager and/or insurance carrier routinely follows up with your treatment and will be notified of cancelled or no-show appointments.

Yes, I acknowledge and understand the Cancellation/No-Show of Care First Rehab.
 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

FINANCIAL POLICY

Thank You for Choosing Care First Rehab
Please carefully review our financial policy. It is important for you to have a thorough understanding of your benefits and responsibilities. Care First Rehab (CFR) Financial Policy is applicable for all patients (clinic and on- location.)

We Gladly Accept:

  • Cash
  • Checks
  • Money Orders
  • VISA / MasterCard / Discover / American Express

Make Payments:

  • Online at www.carefirstpt.com via patient portal
  • Over the phone at: 919.460.1921
  • On-site in our clinic
  • via Mail

Payment-in-Full is Due at Time of Services Rendered

  • Co-Pays and coinsurance amounts, deductibles, and all non-covered items and charges are the insured/patient’s financial responsibility and are due during the Check-In process. Failure to produce payment at Check-In may result in your appointment being rescheduled.
  • If you receive more than 1 type of service on the same day, you may be responsible for more than one Co-Pay.
  • Any amount not covered by the insured/patient’s insurance is due within 30-days of the time of service.
  • Any outstanding balance may incur a $10 monthly statement processing fee, in addition to the initial balance.
  • Failure to pay balances (up to 3 visits); Care First Rehab will “Stop Services” until we receive payment; If no payment is received, we will discharge the patient from CFR.

Missed or Cancelled Appointments | Other Fees

  • Patient must provide 24-hour notice to cancel and/or reschedule all appointments. Failure to do so will result in a $25 “No-Show” fee.
  • All Co-Pays are due at the time of service. Any Co-Pay not received at time of service will result in a $15 processing fee. If Co-Pay is received within 7-days of the date of service, the $15 processing fee will be waived.
  • Checks: $30 fee for NSF (Non-Sufficient Funds).
  • All balances are due prior to any further service provided by our office.
  • Missed and Cancellation fee does not apply to Medicare, Medicaid and CDSA patients.

Credit Card On-File Policy

  • Effective September 1, 2017, Care First Rehab requires that a credit card be on-file for all home-care (on-location) patients. Our therapists are not allowed to accept or process any payments. Please call our office at 919-460-1921 to set-up your account and to answer any questions.
  • DO NOT give any credit card information to your therapist. Patient must contact Front Office at 919-460-1921 .

No Insurance | Self-Pay Patients

  • Patient will be responsible for all fees/services.
  • Care First Rehab requires that a credit card be on-file.

In-Network vs Out-of- Network Insurance

  • Your insurance coverage and benefits are a contract between you and your insurance company, therefore all disputes must be handled between you and your insurance company.
  • If we are out-of- network with your insurance provider, you will be treated as a self-pay patient.
  • Verify insurance benefits requires a 48-hour notice
  • We are required to file with your primary insurance carrier only. It is your responsibility to file charges with any secondary insurance carriers for reimbursement.
  • All charges are your responsibility whether your insurance company pays or does not pay. Not all services are a covered benefit in all contracts. Some insurance companies and some employers decide what is a covered benefit and what is not. Please check your insurance plan document for any questions. Fees for these services along with unmet deductibles and co-payments are due at the time of treatment.

Medicare | Medicaid

  • Medicare. Care First Rehab is a participating provider with the Medicare program and accepts as payment the Medicare allowable, patient deductible and/or 20% co-insurance. Medicare or secondary carriers do not cover some procedures and supplies. Please make certain you understand which aspects of your treatment are covered before proceeding. You understand that you will be responsible for your annual deductible, the co-payment, and any non-covered services specified by Medicare. We may submit a claim to any supplemental plan as a courtesy to you, so long as you provide all necessary policy information.
  • Medicare requires that we provide patients with a written notification whenever it is likely that you will be responsible for a bill.
  • Pending Medicaid – we do not retroactively bill Medicaid for services performed prior to the date of initial eligibility verification. If you have no insurance coverage, you will be considered a self pay patient and will be responsible for all services that you received prior to the initial eligibility date.

Minor Patients

  • Parents or guardians accompanying a minor are responsible for providing current insurance information for the minor as well as the payment-in-full for services provided.
  • In compliance with HIPAA regulations, we are unable to discuss any details of services rendered or to produce an itemized bill for any parties that are not the parent or guardian, unless otherwise documented.
  • Both parents/legal guardians are responsible for payment for services rendered to the minor patient. A copy of this financial policy and all statements will be provided to each parent if living in separate residences.

Auto Accidents | Workers’ Compensation

  • Motor Vehicle Accidents will be filed to your auto insurance as a courtesy to you. Failure to receive payment within 30-days of the date of service may result in your responsibility to pay.
  • Our office will send appropriate Workers’ Compensation claim forms for services rendered on your behalf as a courtesy. If a claim is denied, we will expect payment-in-full from you within 30-days of receipt of our bill (a good faith deposit of 25% is required for longer term of repayment.)
  • Six Month Case Settlement Policy: We will wait for settlement of your claim for up to six months after your care is completed. After the six month mark, patients will be directly responsible for their medical bills. Arrangements can be made to pay the balance.

Payment Plans

  • Please contact our Billing Department to work out a payment plan
  • Mail payments 5-days prior to due date
  • Make Payments Via: Mail, Phone or Online
  • We accept CareCredit, a healthcare credit card that provides 6-months, interest free financing. Visit CareCredit.com to apply online and for further details.

Collections & Outstanding Balances

  • The provider reserves the right to add a $10 monthly statement processing fee on any account that has an unpaid balance.
  • Any outstanding balance after 75-days, from the time of service, may be referred to an outside collection agency. Accounts referred to a collection agency or attorney may be subject to a collection fee of 25%, which will be added to the total balance due at the time of write-off.
  • Patients with unpaid delinquent accounts or accounts sent to collection agency will be discharged from our practice. All services will be stopped.

Refunds

  • Refunds are issued to the appropriate party
  • Patient refunds will not be processed until all active or past due charges are paid-in-full.
  • Refunds less than $10.00 will not be issued, unless otherwise requested; we will credit your account with Care First Rehab. Patients will be notified of this.

Additional Paperwork

  • Any additional paperwork needed to be filled-out by the therapist will result in either a $5 or $10 charge depending on the length of the paperwork.
  • A 48-hour notice is required for all paperwork requests and processing.

Care First Rehab
100 Cornerstone Drive
Cary, NC 27519
Office: 919-460-1921
Fax: 919-460-1929
Website: www.carefirstpt.com
 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
Yes, I acknowledge and understand the Financial Policy of Care First Rehab.

HIPAA NOTICE

HIPAA

Health Insurance Portability and Accountability Act

Legal Duty

Care First Rehab is required by law to protect the privacy of your personal health information, provide this notice about our information practices and follow the information practices that are described herein.

Uses and Disclosures of Health Information

Care First Rehab uses your personal health information primarily for treatment, obtaining payment for treatment, conducting internal administration and evaluating the quality of care that we provide. Some examples of uses of your personal health information may include, but are not limited to, the following: (1) Contacting you by telephone/mail and leaving a message if necessary to provide or obtain information regarding appointments, your treatment, your patient account, treatment alternatives or other health related benefits and services that we offer, and/or company news; (2) Obtaining information from your referral source in order to schedule an appointment and to verify/authorize insurance benefits, (3) Announcing your arrival to the therapist in an area where others may hear the information, (4) Calling out your name in the waiting area, (5) Placing your encounter form and/or medical record in a slot beside your treatment room door, (6) Treating you in an open area where conversations between you and your therapist may be overheard buy other patients and staff, (7) Sharing information as needed with other health care providers involved in your care, (8) Performing quality assurance tasks such as chart review and outcomes analysis, (9) Forwarding information to your insurance carrier in order to receive payment on claims (after obtaining your Medical Records Release and Insurance Assignments), and/or (10) Sharing information to insurers and other entities involved in your workers’ compensation case as authorized by law.

Care First Rehab may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law.

In any other situation, Care First Rehab’s policy is to obtain your written authorization before disclosing your personal information. If you provide us with a written authorization to release information for any reason you may later revoke that authorization to stop future discloses at any time.

Patient’s Individual Rights

You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes.

You may request in writing that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in an emergency circumstance. Care First Rehab will consider all such requests on a case-by- case basis, but the practice is not legally required to accept them

 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

HIPAA NOTICE & FINANCIAL POLICY

The undersigned acknowledges receipt of Care First Rehab’s HIPAA Notice and Financial Policy

 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
If not Patient, Relationship to Patient
Yes, I acknowledge and understand the Hipaa Notice & Financial Policy of Care First Rehab.
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