Intake Forms

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Pelvic Treatment History

Have you had pelvic health PT before?
Have you had any pelvic/female organ related surgeries?
Have you had any pelvic/female organ related cancer?

Play On Physical Therapy strives to provide each patient with the highest quality of care while attempting to accommodate your schedule for your convenience. Therefore, we provide reserved time slots for each patient with a specific therapist in order to minimize your waiting and assure continuity of your treatment. Your consistent attendance of the planned treatment regimen is paramount to your care and recovery. While we are sensitive to the fact that an emergency may occur in a rare instance, cancellations, tardiness, and patient no-shows, decrease our ability to accommodate the scheduling needs of our other patients. We must ask for your full cooperation with the following policy:

  • If you are more than 15 minutes late for your appointment and fail to notify us, treatment may be cancelled and a fee charged for missing the appointment.

  • A scheduled appointment MUST BE CANCELED AT LEAST 24 HOURS IN ADVANCE or a fee will be charged for that appointment.

  • Failure to show up for an appointment (“NO SHOW”) without notifying us will result in a fee being charged for that appointment. Furthermore, 3 consecutive no-shows may result in the cancellation of all remaining scheduled appointments.

  • At week’s end, ALL PATIENTS, regardless of insurance/third party payor, if any, will be charged a $50 CANCELLATION FEE for each late, canceled, or no-show appointment. THE PATIENT IS RESPONSIBLE FOR THE FEE, NOT THE INSURANCE/THIRD PARTY PAYOR.

  • No cancellation fee will be charged if the missed appointment is made up within the same week it was scheduled on a day that you do not have another appointment scheduled.

  • All cancellations and no-shows will be documented in your medical record and appropriately reported to your physician and insurance/third party payor, if any.

We believe that this policy is necessary for the benefit of all our patients, so that we may continue to provide high quality treatment and service to everyone.

All of the staff at Play On Physical Therapy appreciates your anticipated adherence and cooperation with this policy. We wish you the best of luck with your treatment. We are here to help you attain all of your goals and optimize your care and recovery.

By signing below, I acknowledge that I have read the foregoing company policy and agree to its terms.

 I hereby consent to evaluation and/or treatment of my condition by a licensed physical therapist employed by Play On Physical Therapy, LLC. 

The physical therapist has fully explained to me the nature and purposes of the procedures, evaluation and course of treatment. 

The physical therapist has informed me of expected benefits and possible complications or discomfort, which may result from skilled physical therapy care. In addition, the physical therapist has explained to me the risks of receiving no treatment. 

I may experience an increase in my current level of pain or discomfort, or an aggravation of my existing injury or condition. This discomfort is usually temporary; if it does not subside in a reasonable time period, I agree to contact my physical therapist. 

I may experience an improvement in my symptoms and an increase in my ability to perform daily activities. 

I may experience increased strength, awareness, flexibility and endurance in my movements. I may experience decreased pain and discomfort. I should gain a greater knowledge about managing my condition and the resources available to me. 

The physical therapist has explained that there is no guarantee that the proposed course of treatment will improve my condition and that is possible, although unlikely, that the course of treatment may cause additional pain or discomfort or aggravate my condition. 

In order for physical therapy treatment to be effective, I must come to scheduled appointments unless there are unusual circumstances. I understand and agree to cooperate with and perform the physical therapy program intended for me. If I have trouble with any part of my treatment program, I will discuss it with my therapist. 

The term “informed consent” means that the potential risks, benefits, and alternatives of physical therapy treatment have been explained to me. The therapist provides a wide range of services and I understand that I will receive information at the initial visit concerning the treatment and options available for my condition. 

I have been given on opportunity to ask questions, and all my questions have been answered to my satisfaction. I confirm that I have read and fully understand this consent form. In the event of a change in medical status, I understand that my treatment may be modified, stopped, or referred out to the proper practitioner. I reserve the right to withdraw at any time. 

 Play On Physical Therapy is committed to providing our patients with the highest quality care. We thank you for taking the time to read and understand our policy. 

Self-Pay Plan 

Play On Physical Therapy offers a self-pay plan for all individuals who are un-insured or who have an insurance plan with which Play On Physical Therapy does not participate as an in-network provider. 

Self-pay rates are a per visit rate and set by Play On Physical Therapy. The current self-pay fee schedule is attached and is always available upon request from Play On Physical Therapy staff. Self-pay patients are expected to pay in full at the time services are rendered. 

It is the Patient’s Responsibility: 

  1. To know their insurance policy. Patients should be aware of their benefit coverage including which healthcare providers are contracted with their plan and covered and non- covered benefits, authorization requirements, and cost share information such as deductibles, coinsurances, and co-payments. If you are not familiar with your plan coverage, we recommend you contact your carrier directly. 
  2. To obtain a referral from their Primacy Care Provider (PCP) and/or obtain authorization for treatment from their insurance carrier prior to receiving services, if necessary. 
  3. Any non-covered services are the financial responsibility of the patient. 
  4. To pay for treatments at time of service, by cash, check, or charge card unless other mutually agreed upon arrangements have been made. It is the patient’s responsibility to call their insurance company ahead of time, and obtain any pre-authorization that is necessary, and get an estimate of benefits. 

It is Play On Physical Therapy’s responsibility: 

  1. To provide quality medical care. 
  2. To provide patient with a receipt that it is patient’s responsibility to submit to their insurance company to file any insurance claims. 

Financial Policy Acknowledgement 

I have read and understand the above financial policy. I understand that regardless of my insurance claim status or absence of insurance coverage, I am ultimately responsible for the balance on my account for any services rendered. 

Release of Medical Information and Assignment of Benefits 

I authorize the release of medical information necessary for filling health insurance claims for me by Play On Physical Therapy, LLC. I also authorize my insurance carrier(s) to make payment directly to Play On Physical Therapy, LLC. 

Step 1 of 4

Patients/Clients frequently request that we communicate with them by phone, voicemail, email, or text. 

Play On Physical Therapy, LLC respects your right to confidential communications about your protected health information (PHI) as well as your right to direct how those communications occur. 

Since email and texting can be inherently insecure as a method of communication, we will only communicate with you by email or text with your written consent at the email address or phone number you provide to us below. Please be aware that if you have an email account through your employer, your employer may have access to your email. Email, voicemail, and text communications may be filed into your medical record. 

When you consent to communicating with us by email or text you are consenting to email and texting communications that may not be encrypted. Play On Physical Therapy cannot guarantee, but will use reasonable means to maintain, the security and confidentiality of the messages we send. As well voicemail or answering machine messages may be intercepted by others. Therefore, you are agreeing to accept the risk that your protected health information may be intercepted by persons not authorized to receive such information when you consent to communicating with us through phone, voicemail, email, or text. 

Play On Physical Therapy, LLC will not be responsible for any privacy or security breaches that may occur through voicemail, email, or text communications that you have consented to. You may choose to limit the type of voicemail, email, or text communication you have with us if you wish to limit your risk of exposing your protected health information to unauthorized persons. Please indicate below what types of correspondence you consent to receive by email or text. 

Step 1 of 3

During the physical therapy evaluation for the problems you have reported, an assessment of your low back, hips, and pelvic girdle will be performed by a physical therapist in order to identify any musculoskeletal problems. This may include an evaluation of your pelvic floor muscles for strength, resting tone (tightness), and coordination (contract/relax). The findings will be discussed with you, and you will work with your physical therapist to develop a treatment plan that is appropriate for YOU. Your evaluation MAY include an internal assessment of the pelvic floor muscles, which could be completed vaginally (females) or rectally (males & females). A biofeedback assessment of your pelvic floor muscles may also be performed and may include internal or external sensors. Your physical therapist will discuss this option and receive your consent BEFORE initiating this exam. You absolutely can say NO, and your physical therapist can assess and treat the pelvic floor muscles externally (from the outside) if needed. 

If you are pregnant, have an infection of any kind, have an IUD or other implants, have a sexually communicable disease, are less than 6 weeks postpartum or post-surgery, have severe pelvic pain, sensitivity to lubricant, vaginal creams or latex, please inform the therapist prior to the pelvic floor assessment. The assessment of the pelvic floor muscles may result in soreness or discomfort temporarily. If this occurs, please discuss your symptoms with your physical therapist. Evaluation and treatment may result in emotional distress, reproduction of pain, or discomfort, and if you are unable to tolerate the evaluation or treatment you have the right to terminate the therapy session at any time. 

We realize that many patients may be apprehensive because of the private nature of the condition and the examination. Please ask as many questions as you need to increase your comfort and understanding of your evaluation, its findings, and treatment. Please discuss any concerns or hesitation that you may have with your physical therapist. 

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I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. 

I have received this practice’s HIPAA Notice of Privacy Practices (NPP). This NPP provides a detailed summary of the uses and disclosures of my protected health information that made be made by this practice, my individual rights, how I may utilize those rights, and the practice’s legal duties with respect to my information. 

I understand this information can be used to conduct, plan and direct my treatment including subsequent follow-ups with the healthcare providers who are either directly or indirectly involved with my treatment. 

This can also be shared with third party payers to obtain reimbursement. 

I understand that this practice reserves the right to change the terms of its NPP, and to make changes regarding all protected health information controlled by this practice. I understand I can obtain this practice’s current NPP upon request. 

I have been given the right to review such NPP prior to signing this consent. I understand that I may request in writing that this practice restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand that this practice is not required to agree to my requested restrictions, but if the organization does agree, then it is bound to abide by such restrictions. 

Orthopedic and Pelvic Health: Injury Prevention and Treatment

Play On Physical Therapy

Contact Us317-663-0683 (phone) 
317-663-0682 (fax)
By appointment only.
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