I, have been offered or received a copy of the “Notice of Privacy Practices” from Optimal Physical Therapy, LLC or a designated affiliate.

I acknowledge by signing this form I am stating that I am aware of and understand the content of the privacy practices.

Signature:

Date:

Patient Authorization Record Initial here Authorization for Treatment

I hereby give authorization for the performance of such rehabilitation procedures as permitted by Optimal Physical Therapy LLC Statutes under the appropriate scope of practice are, in the judgment of my Therapist, deemed necessary.

Authorization for Release of Information I agree that Optimal Physical Therapy LLC may provide information from my

medical record to persons involved in my medical care. I authorize the release of medical information necessary to obtain payment

of any benefits available to me to Optimal Physical Therapy LLC for services rendered.

I agree that Optimal Physical Therapy LLC may obtain information from others who have provided medical care to me and/or are responsible for the payment of all or part of my bills when this information is needed in order to treat, bill, and/or receive payment.

I have read “Notice of Privacy Practices” mandated by HIPAA. Authorization for Release of Payment

I authorize that direct payment of any benefits available to me be released to Optimal Physical Therapy LLC for services rendered.

Patient Agreement I agree to pay Optimal Physical Therapy LLC charges for services rendered

to me during my course of treatment. I agree to pay those charges which may not be paid by my health insurance

and are my responsibility per my insurance benefit. If I do not pay for charges that are my responsibility, I agree to pay Optimal Physical Therapy LLC collections costs including attorney and court fees.

Medicare, Medicaid, and Similar Benefits I agree that the information given to Optimal Physical Therapy LLC in

applying for benefits under Medicare, Medicaid, and Maternal or Child Health services are complete and accurate. I agree that Optimal Physical Therapy LLC may give Social Security Administration or its fiscal intermediary’s information necessary to process claims.

Workers Compensation I agree that the information given to Optimal Physical Therapy LLC in

applying for benefits under Workers Compensation is complete and accurate. I agree that Optimal Physical Therapy LLC may give intermediary’s information necessary to process claims.

___________________________________________________________________________ Patient signature Date ____________________________________________________________________________ Printed patient name Witness Signature Date ________________________________________________ Signature of Legal Representative/POA (if applicable)

DATE: _________________ Dear Patient, Optimal PT front office staff is working as a courtesy to you to determine eligibility & coverage of your insurance(s) for therapy services. On your behalf, we contacted your insurance company and were provided with the following information: Date of Contact: _________ Phone #: ____________ Name of Contact: ____________________

*This coverage determination does NOT Guarantee payment by your plan.*

According to your insurer:

You are___ are not___ eligible for PT/OT/SLP benefits at this time. Patient’s Responsibility: You have a $__________ total deductible that you have $______ additional dollars due. You have a $__________ co-pay due for each visit. You have a $__________ co-insurance due for each visit. Estimated amount: $________. You have a: PT benefit limit of __# of visits; OT benefit limit __# of visits; SLP benefit limit of __# visits Other Plan Benefit Limits: ____________________________________________________________________________________________________________________________________________________________ We encourage you to call your insurer’s Customer service department to verify your eligibility and coverage as described above. Phone #:________________________________

Please be informed that Optimal Physical Therapy, LLC collects all known co-pays, co-insurances or deductibles at the time of your visit.

How do you plan to pay for the amount determined as your Patient Responsibility? ____ Cash ____ Check ____ Credit/Debit Card: ____ Visa ____ MasterCard _____ American Express Name on Card: ______________________________________________________

Credit Card #: ______________________________ Exp Date: _____CSC: ______ Billing Address: _____________________________________________________ Signature: __________________________________________________________

TO: __________________________________

FROM: __________________________________

ATTN: __________________________________

RE: __________________________________

__________________________________

__________________________________

__________________________________

__________________________________

__________________________________

Pages: __________

This fax message is intended only for the individual to whom it is addressed. It contains information that may be confidential under law. If you’re NOT the intended recipient or agent responsible for the delivering of this message: DO NOT READ, COPY, OR DISTRIBUTE this information. If you received this message by error please contact us at the above address. Thank you.

What to expect after receiving Trigger Point Dry Needling (TDN)

How will I feel after a session of TDN? • You may feel sore immediately after treatment in the area of the body you were treated, this is normal

but does not always occur. It can also take a few hours or the next day before you feel soreness. The soreness may vary depending on the area of the body that was treated as well as varies person to person, but typically it feels like you had an intense workout at the gym. Soreness typically lasts 24-48 hours. If soreness continues beyond this please contact your provider.

• It is common to have bruising after treatment; some areas are more likely than others. Some common areas are shoulders, base of neck, head and face, arms and legs. Large bruising rarely occurs, but can. Use ice to help decrease the bruising and if you feel concern please call your provider.

• It is common to feel tired, nauseous, emotional, giggly or “loopy”, and/or somewhat “out of it” after treatment. This is a normal response that can last up to an hour or two after treatment. If this lasts beyond a day contact your provider as a precaution.

• There are times when treatment may actually make your typical symptoms worse. This is normal. If this continues past the 24 hour – 48 hour window, keep note of it, as this is helpful information and your provider will then adjust your treatment plan based on your report if needed. This does not mean TDN cannot help your condition.

What should I do after treatment, what can I do, and what should I avoid?

• It is highly recommended that you increase your water intake for the next 24 hours after treatment to help avoid soreness.

• It is recommended that you soak in a hot bath or hot tub to help avoid post treatment soreness. • After treatment you may do the following based on your comfort level, if it hurts or exacerbates your

symptoms then stop; Work out and/or stretch Massage the area Use a heating pad Avoid ice unless you are icing a bruise, heat is better for muscle soreness. Drink alcohol, but it is recommended you do not do so excessively. Take Tylenol, Ibuprofen/Motrin, aspirin etc. is ok

If you are feeling light headed, having difficulty breathing, having chest pain or any other concerning symptoms after treatment CALL us immediately. If you are unable to get a hold of us, call your physician.

Trigger Point Dry Needling (TDN)

TDN is a treatment for muscular tightness and spasm which commonly follows injuries and often accompanies the degenerative processes. This muscular tightness and spasm will cause compression and irritation of the nerves exiting the spine. When the nerves are irritated, they cause a protective spasm of all the muscles to which they are connected. This may cause peripheral diagnoses, such as carpel tunnel, tendonitis, osteoarthritis, decreased mobility and chronic pain. Small, thin needles are inserted in the muscles at the trigger points causing the pain referral. The muscles would then contract and release, improving flexibility of the muscle and decreasing symptoms.

4120 South Poplar Street Casper, WY 82601

Phone: (307) 333-2873 Fax: (307) 333-4034

Patient: D.O.B.: Date:

Physician:

Dx:

Treatment Dates: From: To: #of Treatments: #Missed: Treatment Program: Objective measurements from initial visit/present condition: Response to treatment: Therapist’s Recommendations:

[ ] Continue therapy for weeks for ____________________________________________. [ ] Discontinue therapy secondary to patient met all goals. Recommendation for future care or changes in treatment program: Thank you for this referral! Physical Therapist’s Signature Physician’s Recommendations: [ ] Continue present treatment program for weeks. [ ] Continue present treatment program with the following recommended changes:

[ ] Discontinue therapy.

Physician’s Signature Date

PHYSICAL THERAPY EVALUATION Physician: ______________________________________Therapist:______________________________ Patient: ________________________________________Date: _________________________________ Diagnosis: ______________________________________________DOO/DOI/DOS: _______________ Chief complaint/Hx: Pain Scale (0-10): ___________________________________________________________________________________ Pain ↑ with: _______________________________Pain ↓ with: ______________________________________________ Functional Limitations: ______________________________________________________________________________ Diagnostic Tests: ___________________________________________________________________________________ PMH: ____________________________________________________________________________________________ Occupation/Demands: _______________________________________________________________________________ Medications: _______________________________________________________________________________________ Strength: ROM: Palpation: Special Tests: SFMA: Forward bending

ASLR L R

Backward bending

PSLR L R

M.S. Rotation L

R FABER L R

C-S Flexion

Thomas L R

C-S Extension

DF L R

C-S Rotation

L

R SAC (ST) / (LS)

UE Pattern 1 (IR)

L

R

UE Pattern 2 (ER) L

R

SLS L

R

Deep Squat

MedicationsIf you already have a medication

list, please bring in a copy.Dosage Frequency

Height: Weight: Blood Pressure:

At Best:

Pain Scale: 0 = none 5 = Moderate 10 = Extreme

For office use only.

Pain Description (ie.Burning,throbbing,shooting,sharp):Pain Location:

0 1 2 3 4 5 6 7 8 9 10

At Worst:

Current:

Medicare Intake form

Falls HistoryFull Name:

Have you had any falls within the last year? No Yes If yes, how many? Have you had any Injuries related to a fall:

DATE: _________________ Dear Patient, Optimal PT front office staff is working as a courtesy to you to determine eligibility & coverage of your insurance(s) for therapy services. On your behalf, we contacted your insurance company and were provided with the following information: Date of Contact: _________ Phone #: ____________ Name of Contact: ____________________

*This coverage determination does NOT Guarantee payment by your plan.*

According to your insurer:

You are___ are not___ eligible for PT/OT/SLP benefits at this time. Patient’s Responsibility: You have a $__________ total deductible that you have $______ additional dollars due. You have a $__________ co-pay due for each visit. You have a $__________ co-insurance due for each visit. Estimated amount: $________. You have a: PT benefit limit of __# of visits; OT benefit limit __# of visits; SLP benefit limit of __# visits Other Plan Benefit Limits: ____________________________________________________________________________________________________________________________________________________________ We encourage you to call your insurer’s Customer service department to verify your eligibility and coverage as described above. Phone #:________________________________

Please be informed that Optimal Physical Therapy, LLC collects all known co-pays, co-insurances or deductibles at the time of your visit.

How do you plan to pay for the amount determined as your Patient Responsibility? ____ Cash ____ Check ____ Credit/Debit Card: ____ Visa ____ MasterCard _____ American Express Name on Card: ______________________________________________________

Credit Card #: ______________________________ Exp Date: _____CSC: ______ Billing Address: _____________________________________________________ Signature: __________________________________________________________

AUTHORIZATION FOR USE/DISCLOSURE OF HEALTH INFORMATION

Authorization for Use/Disclosure of Information: I voluntarily consent to and authorize my health care provider: Optimal Physical Therapy, LLC to use or disclose my health information during the term of this Authorization to the recipient(s) that have been identified below. Recipient: I authorize my health care information to be released to the following recipient(s): Name:___________________________________________________________ Address:___________________________________________________________ Patient Initial (or guardian if patient is under 18): Purpose: I authorize the release of my health information for the following specific purpose: _______________________________________________________________________. (ie. “at the request of the patient” “Third party request” etc.) Information to be disclosed: I authorize the release of the following health information: (check the applicable box below) All of my health information that the provider has in his or her possession, including

information relating to any medical history, mental or physical condition and any treatment received by me.

Initial

Only the following records or types of health information: __________________________________________________________________.

Initial Term: I understand that this Authorization will remain in effect: From the date of this Authorization until the _____ day of ________, 20___.

Patient Name:Exercise Date

10th Visit?

Notes:

Sign In Labels

Date Time Recorded by123456789

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Optimal Range: 160° - 165° F

Corrective Action

Month: 20___Year:

Hydrocollator Temperature Log

Temperature