New Patient Info

Please review the following and provide any necessary information. Check the boxes if you agree to each statement (below). Click on the highlighted terms to view all documents related to the statement. Your signature will be required to complete. Please remember to bring your insurance cards into the office during your next visit.

It is important to clarify that this form is not integrated into any system and is simply a means for us to collect your information in an organized manner and will still need to be verified by you in person.

Usage Disclaimer



Insurance Information


Referring Physician Information


How did you hear about us?


Notice of Privacy Practices (HIPAA Acknowledgement /Consult)


Release of Information & Consent for Treatment

All information provided herein is true and correct.

I am aware of my diagnosis and wish to receive treatment at Robinet Physical Therapy. I permit its employees and all other persons caring for me to treat me in ways they judge are beneficial to me. I understand that this care can include an evaluation, testing, and treatment. No Guarantees have been made to me about the outcome of this care.

I give permission to Robinet Physical Therapy to release information, verbal and written, contained in my medical record, and other related information, to my insurance company, rehab nurse, case manager, attorney, school, related healthcare provider, assignees and/or beneficiaries and all other related persons as it relates to my treatment or payment for services provided.

I authorize Robinet Physical Therapy to obtain medical records and /or professional information from my physician or other medical professionals as it relates to my treatment.


Assignment of Benefits

I authorize payment directly to Robinet Physical Therapy for any services provided.

This is a direct assignment of my rights and benefits under this policy. A photocopy of this assignment shall be considered as effective and valid as the original.


Cancellation and No Show Policy


Financial Policy and Payment Guarantee

I have read and understand the Financial Policy. I agree to pay Robinet Physical Therapy for the services provided to me or the party named above. If any law, such as worker’s compensation, or insurance contract prohibits payment for these services I will cooperate and assist in the provision of information, authorizations, releases, or any other type of information necessary to allow for speedy collections from my third-party payer. Where the law or an insurance contract does not prohibit payment by me, I acknowledge responsibility for payment of services.

The Benefit Verification form is only an explanation of coverage obtained from my insurance company and it is not a guarantee of coverage. If the information provided by my insurance company is not accurate or the insurance company changes its coverage, I will be responsible for payment of services.

I further understand that this agreement is binding regardless of any legal transaction currently in progress or initialed during or after the course of my treatments unless agreed to in writing by myself and a representative of Robinet Physical Therapy.


PATIENT INFORMATION CONSENT FORM

I have read and fully understand Robinet Physical Therapy Notice of Privacy Practices. I understand that Robinet Physical Therapy may use or disclose my personal health information for the purpose of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the company in writing. I also understand that Robinet Physical Therapy will consider requests for restrictions on a case-by-case basis, but does not have to agree to requests for restrictions.


Designated Individuals Authorization Form

I hereby Authorize one or all of the designated parties (anyone OTHER THAN your physician, insurance company, Workman Compensation Carrier or Employer) listed below to request and receive the release of any protected health information regarding my treatment, payment or administrative operations related to treatment and payment. I understand that the identity of the designated parties must be verified before the release of any information.

Authorized Designees:

Patient or Guardian Signature