NEW PATIENT INTAKE FORM

PATIENT DEMOGRAPHICS
Patient Name: Date of Birth (mm-dd-yyyy):
Address: City: State: Zip Code:
Mobile Phone: SS#: Sex: Male Female
Home Phone: Email:
Status: Single Married Divorced Widowed Seperated Unknown
Race/Ethnicity: American Indian/Alaska Native Asian/Pacific Islander Black/African American
White/Caucasion Hispanic/Latino Multiracial Declined Unavailable
Date of Injury/Onset Date: Auto Related: Y N Work Related: Y N

PRIMARY INSURANCE
Insurance Company: Phone#:
Policy / ID#: Group#:
Policy Holder Name: Policy Holder Date of Birth:
Patient's Relationship to Policy Holder: Self Spouse Child Other

SECONDARY INSURANCE
Insurance Company: Phone#:
Policy / ID#: Group#:
Policy Holder Name: Policy Holder Date of Birth:
Patient's Relationship to Policy Holder: Self Spouse Child Other

EMERGENCY CONTACT
Contact Name: Phone#:
Relationship to Patient: Parent Spouse Child Sibling Other

REFERRING/PRIMARY PHYSICIAN
Physician: Phone#: Fax#:
Address: City: State: Zip Code:

I certify that the information provided is, to the best of my knowledge, true and accurate.

Signature: Date:

Rev 2020
Patient Name: Date:
Acct#:

NOTIFICATION of PATIENT RESPONSIBILITY for CO-PAYMENTS / CO-INSURANCE % and DEDUCTIBLES

Your insurance company requires Penn State Health Rehabilitation Hospital Outpatient Center to collect
your co-payment amount from you at the time of service. If we do not collect these amounts we could be
in violation of our contract with your insurance company and risk being denied reimbursement for your
treatment. Furthermore, we have an obligation to collect any co- insurance % or unmet deductible
amounts from you that are determined to be your responsibility.
You will receive statements from us during and after your treatment for any outstanding amounts your
insurance company indicates will be your financial responsibility. These statements will also include the
amount billed to your insurance company and the payments received from both you and your
insurance company.

BILLING DISCLOSURES TO INDIVIDUALS INVOLVED IN PATIENT’S CARE

There may be times when it is necessary for an individual directly involved in your care to call the
facility to inquire about your personal health information or billing information. Please take a few
moments to complete this section.
I authorize Penn State Health Rehabilitation Hospital Outpatient Center to disclose my health
information that is directly related to my current treatment at Penn State Health
Rehabilitation Hospital Outpatient Center to the individual(s) listed below for purposes of
their role in my treatment or payment or payment for the health services that I have received.
Such persons involved in your care may include: spouse, children, blood relatives, roommates,
boyfriends/girlfriends, domestic partners, neighbors and colleagues.

NAME RELATIONSHIP

I do not wish to have my health information disclosed to individuals involved in my care.

NAME RELATIONSHIP

Penn State Health Rehabilitation Hospital Outpatient Center has verified Outpatient Physical
Therapy/Occupational Therapy/Speech Therapy benefits based on the information furnished to us by you.
Your Insurance Company has the disclaimer that this is verification of benefits and not a guarantee of
payment. Based on the information your insurance company provided to us, the estimated amount you are
responsible for is:
Co-Payment per Visit/Discipline Co-Insurance _ % of allowed amount
Deductible Amount Amount Remaining
Out of Pocket Maximum Amount Remaining
Maximum Visits/Days _ per Year / Contract / Condition / Lifetime
Other Benefit Information

NOTE: ESTIMATED coverage information is provided as a courtesy to our patients, but is not intended to release
them from total responsibility of their account balance. The estimation is based on a negotiated contract and any
remaining balance due will be billed to you after additional information is received from your insurance company.
We are committed to Service Excellence to our patients. If you have questions or concerns about your billing, please
contact our Centralized Business Office at (866) 889-9968. Thank you.
Rev 2020
Statement of Financial Responsibility; Consent to Treatment;
Authorization to Release Information

Patient Name: Date: Acct#:

STATEMENT OF FINANCIAL RESPONSIBILITY

Penn State Health Rehabilitation Hospital Outpatient Center appreciates the confidence you have shown in
choosing us to provide for your rehabilitative needs. The service you have elected to participate in implies a
financial responsibility on your part. This responsibility obligates you to ensure payment in full of your fees. As
a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. However, you are
ultimately responsible for the payment of your bill.
You are responsible for payment of any co-payment at the time of service and for any deductible /coinsurance as
determined by your contract with your insurance carrier. Many insurance companies have additional stipulations
that may affect your coverage. You are responsible for any amount not covered by your insurer. If your insurance
carrier denies any part of your claim, or if you and your physician elect to continue therapy past your approved
period, you will be responsible for your account balance in full. If your account is not paid in full and is referred to a
collection agency, any fees incurred in collecting on your unpaid balance will be your responsibility. For your
convenience, we accept cash, checks and most major credit cards. Payment is expected by payment due date on
your Monthly Patient Statement. Payments can be made at the center, mailed to the address on your statement, or
you may access our on-line bill payment option @ https://pay.instamed.com/kesslerbillpay once a statement is
received from the billing office, or by calling our customer service department at 1-866-889-9968.

I have read the above policy regarding my financial responsibility to Penn State Health Rehabilitation
Hospital Outpatient Center for providing rehabilitative services to the above named patient or me. I
certify that the information provided is, to the best of my knowledge, true and accurate. I authorize my
insurer to pay any benefits directly to Penn State Health Rehabilitation Hospital Outpatient Center. I
agree to pay Penn State Health Rehabilitation Hospital Outpatient Center the full and entire amount of
all bills incurred by me or the above named patient, if applicable, any amount due after payment has
been made by my insurance carrier.

Signature: Date:
(relationship to patient: self – guardian – other: )

AUTHORIZATION TO UTILIZE CONTACT INFORMATION

I agree that in order for Penn State Health Rehabilitation Hospital Outpatient Center to collect any
amounts I may owe, Penn State Health Rehabilitation Hospital Outpatient Center may contact me by
any telephone number associated with my account, including wireless telephone numbers, which could
result in charges to me. We may also contact you by sending text messages or emails, using any email
address I provide to Penn State Health Rehabilitation Hospital Outpatient Center. Methods of contact
may include using pre- recorded/artificial voice messages and use of automatic dialing devices, as
applicable.

Signature: Date:
(relationship to patient: self – guardian – other: )

Rev 2020
Statement of Financial Responsibility; Consent to Treatment;
Authorization to Release Information

Patient Name: Date: Acct#:

NOTICE OF PRIVACY PRACTICES

I acknowledge that the Notice of Privacy Practices and Notice for Federal Civil Rights is posted
at the location in which I am receiving treatment and that I have read and understand the notice. I
further acknowledge that I have the right to request a copy of the notice and one will be provided to
me.

Signature: Date:
(relationship to patient: self – guardian – other: )

CONSENT TO TREATMENT
I am aware of my diagnosis and voluntarily consent to have Penn State Health Rehabilitation Hospital
Outpatient Center, through its appropriate personnel, provide evaluation and/or treatment as prescribed
by my physician and/or recommended by my therapist. I understand the practice of physical, speech,
and occupational therapy is not an exact science, and I acknowledge that no guarantees have been
given to me regarding the successful completion or the results of the treatment provided. I understand
that the treatment I receive from Penn State Health Rehabilitation Hospital Outpatient Center is limited
to physical, speech, and/or occupational therapy services and that I shall seek treatment from other
medical professionals for all other issues I may experience. I understand that I have the right to ask
questions at any time during the course of my care.

Signature: Date:
(relationship to patient: self – guardian – other: )

AUTHORIZATION TO RELEASE INFORMATION

I further authorize Penn State Health Rehabilitation Hospital Outpatient Center to release to
appropriate agencies, any information acquired in the course of my or the above named patient’s
examination and treatment necessary to secure payment for services provided.

Signature: Date:
(relationship to patient: self – guardian – other: )

Rev 2020
 Outpatient Medical History / Screening Form

To Be Completed By The Patient / Family / Caregiver

Patient Name:_____________________________________ Spoken Languages:____________________________________

Preferred language to receive healthcare information for patient: ______________________________________________________
Preferred language to receive healthcare information for legal guardian / healthcare proxy : ________________________________
Emergency Contact:_________________________________ Telephone # :_________________________________________
Family Physician / Internist:____________________________ Telephone # :_________________________________________
Religious / Cultural Needs: NO YES Please Explain:_________________________________________________
Special Learning Needs: NO YES Please Explain:_________________________________________________
Hearing Difficulty: NO YES Speaking / Communication Difficulty: NO YES
Why are you here?_________________________________________________ Date of Injury: _____________________________

Medical Information:
Patient Family History
YES NO YES NO YES NO
Diabetes Diminished Sensation / Numbness
Hypertension (high blood pressure) Skin Sensitivities:
Heart Attack Latex Adhesives Temperature
Heart Disease History of Pressure Sores
High Cholesterol Pacemaker / Defibrillator
Smoking Bleeding / Bruising (recent history)
Chest Pain / Angina Hypoglycemia (low blood sugar)
Light-Headedness / Dizziness / Fainting Active seizure disorder
Hypotension (low blood pressure) Dementia / Alzheimer's
Shortness of Breath Kidney Disease
Ankle Swelling Asthma
Night Coughing * Always have inhaler with you
Cancer / Tumors / Growths Lung Disease / Emphysema / COPD
*Radiation / Chemotherapy Treatment * Oxygen use
Osteoporosis Are You Pregnant?
Osteoarthritis
Rheumatoid Arthritis In the past month, have you frequently been
Rheumatic Disease bothered by feeling down, depressed or
Stroke hopeless?
Multiple Sclerosis In the past month, have you frequently been
Brain Injury bothered by having little interest in things or
Spinal Cord Injury have you lost pleasure in doing things?
Fractures: Fractures Other:
DATE:_________ AREA:__________________________ ___________________________________________________
DATE:_________ AREA:__________________________ __________________________________________________
In the past three months have you experienced: Are you in pain? YES NO
Changes or difficulty with Bowel Location of pain:____________________________________
Changes or difficulty with Bladder If you answered yes to any of the above:
Night Sweats Are you under the care of a physician for these conditions?
Fever YES NO
Allergies: ________________________________________________________________________________________________
_________________________________________________________________________________________________________
Surgery(s) within last 3 months - Include Dates: __________________________________________________________________
What are your Rehabilitation goals?___________________________________________________________________________

Revised: 09/2013 Page 1 of 2

 Medical Information:
If you need information regarding Advanced Directives, please contact the site Patient Service Specialist.
Advanced Directives are not honored in the Outpatient Setting.
FALL RISK ASSESSMENT* NO NUTRITIONAL SCREENING
YES YES NO
Have you fallen within the last year? Unexplained weight loss
If so, how many times? ___________________________ (>5% in last 30 days)
Have any of these falls resulted in an
Recent loss of appetite / aversion to food?
injury within the last year?
Are you afraid of falling? Do you have difficulty swallowing?
Have you recently felt unsteady on your Decrease in food intake?
feet or in your wheelchair? (<50% for 3 days or more)
Are you under the care of a physician for
Do you experience dizziness or vertigo?
these conditions?
Do you have vision problems that CURRENT MEDICATION (List below)
are not corrected by glasses? I provided separate list of medications:
Do you use sedatives that affect your I am currently not taking any over the counter or
level of alertness during the day? prescribed medications / herbals:
Do you have memory / cognitive
difficulties?
Do you have a lower extremity
disability that affects walking?
AS PER CMS FALL SCREENING CRITERIA
*Patient is considered a fall risk if patient has fallen two or more times in
the past year
*Patient is considered a fall risk if patient has fallen one time with resulting
Are all meds prescribed by a physician? YES No NO
injury in the past year
* FALL RISK - Patient is considered a fall risk if they answer yes to three or more fall risk assessment questions, if they meet CMS screening
criteria for fall risk, or if therapist judgment indicates. Clinician should refer to the Fall Prevention Policy in the OP PSHR P&P manual (PC OP 1018).

Please inform your therapist of any changes in medications, medical conditions or surgeries so this
summary list can be updated as you progress in your treatment.

PATIENT SIGNATURE:_____________________________________________DATE:_______________________
UPDATES:
Please list changes to medication:

Please list changes to medical condition / surgeries:

PATIENT SIGNATURE:__________________________________________________NEW DATE:____________________

This information will be used as a guide to your treatment plan. If you need any medical follow-up, please contact your physician.
To Be Completed By Evaluating Therapist
Patient has been identified as a fall risk : YES NO
Patient has been identified as a nutrition risk : YES NO (If yes, notify MD)
Patient would benefit from a Social Services referral: YES NO (yes if therapist feels patient life is threatened / patient is a threat to others)
Therapist Signature: Date: Time:
Therapist Signature: Date: Time:
Therapist Signature: Date: Time:
Therapist Signature: Date: Time:
Therapist Signature: Date: Time:
Therapist Signature: Date: Time:
(Therapist has reviewed medical history form with patient)
Revised: 05/2020 Page 2 of 2