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F Squared Physical Therapy

One Patient One Hour

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      • Dr. Paul Ochoa
      • Dr. Monique Dupree
      • John Wilbert
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Medical History

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important questions.

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  • So we can send them a Thank You!
  • 0 is least pain - 10 is most pain
  • If yes, please list all medications.
  • Enter other here
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  • Neck Index

    This questionnaire will give your provider information about how your neck condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem.
  • Index Score = [Sum of all statements selected / (# of sections with a statement selected x 5)] x 100
  • Over the last 2 weeks, how often have you been bothered by the following problems?
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  • DASH Score - Disabilities of the Arm, Shoulder and Hand

    Please rate your ability to do the following activities in the last week by checking the number beside the appropriate response.

  • Please rate the severity of the following 5 symptoms in the last week.
    (# 24 thru # 28 )
  • ( [(sum of n responses / n) - 1] x 25, where n is the number of completed responses.)
  • Over the last 2 weeks, how often have you been bothered by the following problems?
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  • Back Index

    This questionnaire will give your provider information about how your back condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem.
  • Index Score = [Sum of all statements selected / (# of sections with a statement selected x 5)] x 100
  • Over the last 2 weeks, how often have you been bothered by the following problems?
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  • Lower Extremity Functional Scale

    We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your lower limb problem for which you are currently seeking attention. Please provide an answer for each activity.

    Today, do you or would you have any difficulty at all with:

  • SCORE: _____/ 80
  • Over the last 2 weeks, how often have you been bothered by the following problems?
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  • F2PT Demographics Form

  • Your email will be your account username.
  • This is your account password.
  • MM slash DD slash YYYY
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  • Insurance Information

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  • Patient Responsibilities

  • - I request that payment of benefits be made on my behalf to F Squared Physical Therapy for any services rendered.

    -I understand and acknowledge that submission of claims is not a guarantee of payment. If for any reason my carrier does not cover and/or all of my physical therapy treatments, I agree that I am responsible for the payment of the entire amount.

    -I understand that it is my responsibility to obtain a new prescription at the end of the specified time period. If I fail to obtain an updated prescription, I understand that I will be responsible for payment of services not covered by my carrier.

    -I understand that it is my responsibility to make sure that my bills are paid in a reasonable time (no longer than 1 month from the date of treatment). If for any reason any portion of my bill is not paid, I understand that I am financially responsible for charges for services rendered.

    -I understand and agree that if my carrier makes any payments directly to me for services rendered, i will remit the same payment to F Squared Physical Therapy.

    -I understand that it is my responsibility to notify F Squared Physical Therapy of any changes to my insurance carrier or coverage as soon as possible. Any failure to report such changes will result in the patient being financially responsible for any lapse in coverage or authorization.

    -I herby authorize F Squared Physical Therapy to release all information necessary to secure payment of benefits. I authorize the use of this signature on all insurance submissions.

    -I understand it is my responsibility for submitting and following through for reimbursement through my insurance for services rendered by F Squared Physical Therapy when paying for service out of pocket. F Squared Physical Therapy is not held responsible for insurance reimbursement in this situation.
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  • Waiver of Liability

  • In agreeing to receive care provided by F Squared Physical Therapy and to use the facilities provided therefore by F Squared Physical Therapy located at 250 West 26th Street Suite 402, New York, New York, 10001 I agree as follows:

    I fully understand and acknowledge that (a) the activities in which I will engage as part of the treatment provided by F Squared Physical Therapy and the physical therapy activities and equipment I may use as a part of that treatment have inherent risks, dangers, and hazards and such exists in my use of any equipment and my participation in these activities; (b) my participation in such activities and/or use of such equipment may result in injury or illness including, but not limited to bodily injury, disease, strains, fractures, partial and/or total paralysis, death or other ailments that, could cause serious disability; (c) these risks and dangers may be caused by the negligence of the representatives or employees of F Squared Physical Therapy, the negligence of the participants, the negligence of others, accidents, breaches of contract, or other causes. By my participation in these activities and for use of equipment, I hereby assume all risks and dangers and all responsibility for any losses and/or damages whether caused in whole or in part by the negligence or the conduct of the representatives or employees of F Squared Physical Therapy, or by any other person.

    I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify F Squared Physical Therapy their representatives, employees, and assigns from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my use of any equipment or participation in these activities. I specifically understand that I am releasing, discharging, and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the representatives or employees of F Squared Physical Therapy.
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  • Cancellation Policy

  • -I acknowledge there is a 24-hour Cancellation Policy and understand that if I do not cancel 24 hours before my scheduled appointment, I accept the responsibility of being charged $100.00.

    -I understand arriving later then 20 minute after my scheduled appointment time is considered a "no-show" and I will be charged $100.00.

    -I understand that I will not be seen if I arrive later then 20 minutes after my scheduled appointment.

    -I understand that I am responsible for my deductible, co-payments, and all late cancellation or no-show fees if applicable.

    -I understand if I "no-show" to 3 consecutive appointments, my scheduled appointments will be cancelled and I will need to call to make future appointments on a "same-day" basis.
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  • Consent For Telemedicine Services

  • Introduction

    Telemedicine is the delivery of healthcare services when the healthcare provider and patient are not in the same physical location through the use of technology. Providers may include primary care practitioners, specialists, and/or subspecialists. Electronically-transmitted information may be used for diagnosis, therapy, follow-up and/or patient education, and may include any of the following:

    • Patient medical records.
    • Medical images.
    • Interactive audio, video, and/or data communications.
    • Output data from medical devices and sound and video files.

    The interactive electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

    Potential Benefits:

    1. Improved access to medical care by enabling a patient to remain in his/her physicians’s office (or at a remote site) while the physician obtains test results and consults with healthcare practitioners at distant/other sites.
    2. Obtaining the expertise of a distant specialist.

    Potential Risks:

    As with any medical procedure, there are potential risks associated with the use of telemedicine.

    These risks include, but may not be limited to:

    1. Information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s).
    2. The consulting physician(s) are not able to provide medical treatment to the patient through the use of telemedicine equipment nor provide for or arrange for any emergency care that I may require.
    3. Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
    4. Security protocols could fail, causing a breach of privacy of personal medical information.
    5. A lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other medical judgment errors.

    By signing this form, I understand and agree to the following:

    1. The laws that protect the privacy and confidentiality of medical information also apply to telemedicine. No information obtained during a telemedicine encounter which identifies me will be disclosed to researchers or other entities without my consent.
    2. I have the right to withhold or withdraw my consent to the use of telemedicine during the course of my care at any time. I understand that my withdrawal of consent will not affect any future care or treatment, nor will it subject me to the risk of loss or withdrawal of any health benefits to which I am otherwise entitled.
    3. I have the right to inspect all information obtained and recorded during the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
    4. A variety of alternative methods of medical care may be available to me, and I may choose one or more of these at any time. My physician has explained the alternative care methods to my satisfaction.
    5. Telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out-of-state.
    6. I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured. My condition may not be cured or improved, and in some cases, may get worse.

    Patient Consent To The Use of Telemedicine

    I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.

    I hereby consent to and authorize F Squared Physical Therapy to use telemedicine in the course of my diagnosis and treatment.

    I understand this service may not be a covered benefit under my insurance plan and that I am ultimately responsible for the total cost of the visit.

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19 West 21st Street, RM 901
New York, NY 10010

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T: 212-675-5650
F: 646-844-7634
E: frontdesk@f2pt.com