Patient Registration

Today's Date * +

Clinic Where Appt is Scheduled? *

How did you first hear about us?

Patient First Name *

Patient Last Name *

Middle Init

Date of Birth *

Responsible Party for Minor Child (Include Responsible Party Name, Mailing Address, DOB, DL#):

Gender *

Marital Status

Attach Image of Driver's License

Mailing Address *

City *

State *

Zip *

Best Phone Number *

Phone Type *

Email Address

Social Security # or Drivers' License #
SS# required if filing a Work Comp claim
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Emergency Contact

Emergency Contact Ph#

Primary Insurance Information

Primary Insurance Company *

Subscriber ID / Policy #

Relationship

Is this a MEDICARE or MEDICAID policy? *

Primary Subscriber Name

Subscriber DOB

Attach Image of Insurance Card (FRONT)

Attach Image of Insurance Card (BACK)

Secondary Insurance Information

Secondary Insurance Company

Subscriber ID / Policy #

Relationship

Is this a MEDICARE or MEDICAID policy?

Subscriber Name

Subscriber DOB

Attach Image of Insurance Card (FRONT)

Attach Image of Insurance Card (BACK)

Text Message Communication Consent

Cell Phone # (If no cell, enter 0s) *

Text Message Communication *

Opt-In to receive text message communication

Opt-Out to decline

I authorize Genesis Physical Therapy to send text message communications to me on my provided cell phone number. I understand that I may reply with various commands to receive account information such as balances, future appointments, office location and other alerts. I understand that text messaging is not a secure format of communication. There is some risk that individually identifiable health information or other sensitive or confidential information contained in such text may be misdirected or intercepted. Information included in text messages may include your first name, date/time of appointments, name of physician, and physician phone number, or other pertinent information. Text message charges from my cell phone provider may apply. By signing below, I indicate I am the person legally responsible for use of cell phone number, that I am at least 18 years of age, and that I agree to all terms and conditions of use for the text messaging services. Text message charges from my cell phone provider may apply. I know that I am under no obligation to authorize Genesis Physical Therapy to send me text messages. I may opt-out of receiving these communications at any time by calling the Service Desk @ (601) 898-4324. Please allow 2-3 business days for processing. *

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Consent and Authorizations

AUTHORIZATION FOR USE/DISCLOSURE OF INFORMATION: Many of our patients allow family members such as their spouse, significant other, parents or children to call and request the result of tests, procedures and financial information. Under the requirements for H.I.P.A.A. we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your medical information, any test results and/or financial information released to any family members you must sign this form. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent. I voluntarily consent to an authorize my health care provider at Genesis Physical Therapy Group to use or disclose my health information during the term of this Authorization to the recipient(s) that I have identified below.

	Name	Relationship to Patient	Name	Relationship to Patient
`	Name	Relationship to Patient	Name	Relationship to Patient
`	Name	Relationship to Patient	Name	Relationship to Patient

RELEASE OF MEDICAL TREATMENT: The undersigned authorizes Genesis Physical Therapy to release the Patient’s health information as needed to process insurance claims. The undersigned understands Genesis Physical Therapy participates in various insurance programs with insurance carriers and may be required to submit the Patient’s health information to the Patient’s insurance carrier. PAY BENEFIT CLAIMS: The undersigned assigns payment directly to Genesis Physical Therapy for all insurance and similar benefits otherwise payable to the Patient by virtue of medical treatment provided by Genesis Physical Therapy, but not to exceed regular charges for medical treatment. The undersigned understands the Patient is financially responsible for charges not covered by insurance and agrees that the Patient shall be responsible for all charges incurred, regardless of the status of medical insurance or similar benefits. CONSENT FOR TREATMENT: The undersigned authorizes and consents Genesis Physical Therapy to furnish medical treatment that the Therapist and/or Physician consider necessary and proper in the treatment of the Patient. In doing so, I understand that such rehabilitation and related services may involve bodily contact, touching, and/or direct contact of a sensitive nature, including but not limited to areas of my body I may consider sensitive and/or private. PAYMENT TERMS: The undersigned understands that payment in full is due on the date of treatment for all services provided and the undersigned agrees to pay all charges for the Patient. Genesis Physical Therapy does not issue refunds or invoices for debits/credits less than $5.00. After 90 days, balances under $5.00 will be written off and credits under $5.00 will be retained by Genesis Physical Therapy. I acknowledge a $30 fee will be added to my account for returned checks. I understand that if I fail to pay the balance in full within (30) days after the last date of service, a late fee will be added that is twenty-two percent (22%) of the unpaid balance. I understand that if I fail to pay the balance in full within (30) days after the last date of service, this account can be referred to a collection agency. If I fail to pay any balance in full and am referred to a collection agency or attorney, I agree to pay any cost of collections, attorney fees, and cost of court. VALUABLES: The undersigned hereby releases Genesis Physical Therapy and its employees from any responsibility due to loss or damage of any valuables while on the premises of Genesis Physical Therapy. CANCELLATION / NO SHOW FEE: In an effort to enhance each of your therapy visits, we strongly encourage regular attendance. If it is necessary to cancel your scheduled appointment, we require that you call our office at least 24 hours in advance. Failure to notify our office 24 hours in advance can result in a $35.00 fee. This policy also applies to not showing up for your current and any future scheduled appointments. WORKERS' COMPENSATION PATIENTS: I understand that if this is a Workers' Compensation injury, I authorize and consent Genesis Physical Therapy to release information to the Workers' Compensation Insurance Company and/or Workers' Compensation Employer. Additionally, your physician feels that you have a need for therapy, so it is imperative that you come to all of your therapy sessions. In the event you feel you will be unable to keep your scheduled appointment, it is your responsibility to take the following steps: 1) Contact Genesis, 2) Contact your Work Comp Adjuster, 3) Contact your Physician to explain any missed appointments. It is our policy to contact your Physician, Workers' Compensation Insurance Company, and/or Workers' Compensation Employer with explanations of any and all missed appointments. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES: Designated Privacy Official: (601) 898-7561. I hereby acknowledge that I have received, reviewed, and understand the Genesis Physical Therapy Notice of Privacy Practices. You may request at any time to receive a copy of this notice for your records. RELEASE OF INFORMATION: Unless otherwise authorized by this document or by law, Genesis Physical Therapy will only release the Patient’s health information to the undersigned. The undersigned may specify below to whom the Patient’s health information may be released. This information would include but not limited to medical information, billing, and other protected health information.
* I certify that I have read, understand, and agree to the above Consent and Authorizations.
* By signing my name electronically on this Consent and Authorizations Form, I am agreeing that my electronic signature is the legal equivalent of my manual signature on this form.

Signature of Patient OR Responsible Party for Minor Child:
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If you are not able to finish paperwork or submit online,

please arrive to your appointment 30 minutes early to complete paperwork.