Thank you for visiting Care First Rehab. We want your visit to be pleasant and comfortable.Please help us by completing this form
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:
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:
Have you had therapy previously for the same problem?
Yes
No
If Other, please list:
Speech Concerns
SELECT all that apply
Adult/Geriatric Swallowing
Please list any medications you are currently prescribed:
Medication
Strength
Dosage/How Often? Last Dose?
PAIN
Do you have pain now?
Location/Type:
What makes it better?
What makes it worse?
Does the pain interfere with your daily life?
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:
Physician/Practice Name:
Last Appointment Date with the Primary Physician:
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
Child Medical History
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
Rate your pain on a scale of 0-10 (0 Being No Pain and 10 being Worst Pain)
Rate your pain
Developmental Milestones
If delayed, please explain:
If delayed, please explain:
If delayed, please explain:
Speech Concerns
Speech History
What are you biggest concerns regarding your child’s speech and language skills?
If no, what is the language?
If no, does your child understand and speak English Language?
SELECT all that apply
Occupational History/Daily Routine:
Hand preference :
Meal Time
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 manage
Self Help Skills
Can your child independently:
Any behavioral concerns during routine hygiene tasks?
Social/Play Skills:
Additional Information
What are your biggest concerns regarding your child’s fine motor skills?
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:
Availability
Please enter the school/daycare name
Please check the appointment availability:
Place Of Service:
Home
Other
If other, please specify:
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
APPOINTMENT CANCELLATIONS & NO-SHOW POLICY
Cancellations
Must Notify Care First Rehab 48-hours in Advance if you miss 2 appointments without calling 48 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 $50 Fee
Care First Rehab understands that on occasion emergency situations may occur that prevent 48-hour notice. Inclement weather is one such situation.
These cases will be handled on an individual basis at the discretion of the Administrative Office.
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.
Cancellations
Must Notify Care First Rehab 48-hours in Advance if you miss 2 appointments without calling 48 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 $50 Fee
Care First Rehab understands that on occasion emergency situations may occur that prevent 48-hour notice. Inclement weather is one such situation.
These cases will be handled on an individual basis at the discretion of the Administrative Office.
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 Appointment Cancellations & No-Show Policy 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
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.
Contact Us
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.
Consent Release Form – Outside therapy and Media publication
Outside Therapy
I give Care First Rehab permission to take my(self)/child’s therapy session outside,
around the building premises during the session.
OR
No, I don’t give consent for Outside Therapy
Media Publication
I give Care First Rehab permission to take my(self)/child’s picture to use, reproduce, and publish photographs, testimonials, statements, and/or video content that may contain my image, likeness, and/or voice. I understand that this Content may be used in publications, press releases, marketing materials,
advertisements (both digital and print), websites (including social media sites), or other uses.
I agree and understand I shall neither be compensated for the content nor receive attribution for the content. This authorization is continuous, and only I may withdraw this authorization
through specific, written rescission. I hereby release from any liability of any kind related to the use, reproduction, or publication of the Content.
OR
No, I don’t give consent for Media Publication.
PATIENT OR PARENT/GUARDIAN SIGNATURE
DATE & IP ADDRESS
Consent for Telehealth Therapy
Telehealth therapy is the use of electronic information and communication technologies by licensed therapists to
deliver services to an individual when he/she is located at a different site than the provider.
The laws that protect privacy and the confidentiality of medical information also apply to telehealth therapy. As always, your insurance carrier will have access to your medical
records for quality review/audit. Care First Rehab uses an electronic platform that is HIPPA Complaint and sessions are never recorded or stored.
PATIENT OR PARENT/GUARDIAN SIGNATURE
DATE & IP ADDRESS
