I consent to hands-on treatment and evaluation necessary for the care of the above patient.
I authorize the release of all medical records, copies of this authorization, and any information necessary for my treatment
or claim to my health care providers and their billing agents as needed.
I authorize The New Jersey Centers of Physical Therapy to appeal any insurance denials on my behalf as my
I have been made aware that The New Jersey Centers of Physical Therapy is Out of Network with most Insurance
Companies. I understand that I have the opportunity to be serviced by an In-Network provider and instead, I have
specifically selected the services of this Out-of-Network Health Care Provider.
I have discussed my financial obligations with a Client Care Specialist at The New Jersey Centers of Physical Therapy and
understand my shared responsibility.
I must provide The New Jersey Centers of Physical Therapy with all Checks and Explanation of Benefits I receive from my
insurance company for services provided. I will forward these payments within one week of receiving them. These payments
are the legal property of The New Jersey Centers of Physical Therapy.
I agree to call The New Jersey Centers of Physical Therapy before my scheduled appointment if I need to cancel. If I do not
call to cancel an appointment I agree to pay a $20.00 charge for each occurrence.
HIPAA PRIVACY PRACTICE NOTICE
Effective Date: April 14, 2003, Revised Date: September 23, 2013
The New Jersey Centers of Physical Therapy is required by law to maintain the privacy of and provide individuals with a copy of our legal duties and privacy
practices with respect to protected health information. This means The New Jersey Centers of Physical Therapy will not give out any of your personal
information without your consent. THE NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION, you have the right to request the Notice of Privacy Practices prior to
signing this consent.
If you have any questions about this notice, please contact The Director of Clinical Services at The New Jersey Centers of Physical Therapy, 69 Newark
Pompton Turnpike, Riverdale, NJ 07457, 973-248-8111
I have read and fully understand all of the above.
Have you had any diagnostic testing?
None –12345678910 – Worst imaginable
Select the areas where you’re experiencing pain:
OTHER :StomachChestLower BackUpper BackNeckHead
Constant (76-100% of the time)Frequent (51-75% of the time)Occasional (26-50% of the time)Intermittently (0-25% of the time)
YN Fever/ Chills/ Sweats
YN Unexplained weight change
YN Nausea/ Vomiting
YN Dizziness/ Lightheadedness
YN Numbness/ Tingling
YN Shortness of breath
YN Changes in bowel/ bladder function (difficulty, frequency, etc.)
Are you currently pregnant?
Are you taking fertility drugs? if yes,
YN Angina/ Chest Pain
YN Kidney Disease
YN High Blood Pressure
YN Circulation Problems
YN Rheumatoid Arthritis
YN Other Arthritic Conditions
YN Multiple Sclerosis
YN Thyroid Problems
YN HIV / AIDS
YN Allergies: If yes,
YN Cancer: If yes,
YN Chemical dependency (e.g alcoholism): If yes,
YN Heart Disease/ Heart Attack: If yes,
Choose your Location