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MEDITOUCH CLINIC DMTPATIENT INFORMATION FORMName:Date of Birth:Address: City: State: Zip Code:Home Phone: Work Phone:Cell Phone: Email:Emergency Contact Name:Relationship to Emergency Contact: Emergency Contact #:Sex: MaleMarital Status: SingleFemaleEmployedr: YesNoFull-time StudentDiagnosis: RightReferring Doctor:Copy of Referral: YesMarriedNoOtherPart-time StudentLeftBilateralPhone #:Fax #:Insurance Company: Relationship to Subscriber: SpouseChildSelfSubscriber’s DOB: Subscriber’s Address:Subscriber’s #: Group #:Copy of Card in Chart: Yes No NoSecondary Insurance:YesInsurance’s Phone #: Fax #NoI understand, as the patient and/or above-mentioned responsible party, that I am fully responsible for payment of allcharges incurred.I authorize my insurance benefits to be paid directly to Diversified Movement Therapy for services rendered. Iunderstand I am financially responsible for any deductibles, non-covered services, or non-authorized services.I am aware of the 85.00 cancellation fee and agree to pay that amount if I do not give 24 hours of notice beforecancelling my appointment.I authorize Diversified Movement Therapy to release any information requested by the insurance company with regardsto payment of benefits.SIGNATURE: Date:
DIVERSIFIED MOVEMENT THERAPY MEDITOUCH CLINICParkland Building875-140th Avenue NE, Suite 103Bellevue, WA 98005Medical HistoryName:Diagnosis:Date of Injury:Dominant Hand: LeftRightDate of Birth:Date of Surgery: (if applicable)Please list significant past injuries or surgeries relevant to the condition for which you are seeking treatment:Type: Year:Type:Year:Type:Year:Please check the appropriate space if you have had any of the following:Immune nBowel/Bladder AbnormalitiesLupusCardiovascular DiseaseLyme DiseaseCauda Equina SyndromeMultiple SclerosisCurrent InfectionMuscular DystrophyDiabetes Mellitus Type 1OsteoarthritisDiabetes Mellitus Type 2OsteoporosisDizziness/FaintingPacemakerFracture or Suspected FractureParkinson’sFibromyalgiaPsychiatric DisordersGastrointestinal IssuesRheumatoid ArthritisHepatitisSkin Disease(s)High Blood PressureSpinal Cord InjuryHistory of CancerStrokeHistory of Fall(s)Traumatic Brain InjuryOther (Please describe below)If yes, please indicate the date(s) belowDescriptionNoIf female, are you pregnant? YesHave you recently experienced:Depression/AnxietyDifficulty SleepingDecreased Activity LevelsNumbness/TinglingEdemaHeadachesNight PainOtherPlease continue to the next page and sign the consent to treat
Please list any allergies you have:Please list medications you are currently taking, the amounts, frequency and the reason for the medication:Consent for TreatmentI hereby give my consent for the authorized personnel at Diversified Movement Therapy Meditouch Clinic toevaluate me and render subsequent treatment in accordance with the plan of care authorized by the therapistand/or physician. I authorize release of any medical information to my physician and therapist as needed toevaluate and treat me. I also authorize release of medical information to my insurance carrier as appropriate forbilling purposes.Patient Signature Date
Please mark the areas of pain on the body diagram below:ClearWhen do you experience the most pain?How often do you experience pain in the area that hurts the most?ConstantlyPlease rate your pain for the area that hurts the most:NoPainAt its worst in the last 24 hours:At its least in the last 24 hours:Worst PainPossibleAt present:Please check the box after the word(s) that describe your pain ingSharpIf you have nerve symptoms, please check the box by the word(s) that best describes the symptom(s):NumbnessTinglingPins and NeedlesHypersensitivityPlease check the box by the areas of your life in which your pain interferes?Enjoyment of f-careHobbies/LeisureSocial Activities/RelationshipsSleepWorkOther:Please list three specific activities that are difficult, impossible or painful to mpossible3.DifficultPainfulImpossibleWhat is your goal for therapy?
MEDITOUCH CLINIC DMTNOTICE OF PRIVACY RIGHTSEffective 09/20/2017The Health Insurance Portability and Accountability Act of 1995 is a federal program that requires thatall medical records and individually identifiable health information used or disclosed by us be keptproperly confidential. As required by HIPAA, following is an explanation of how we are required tomaintain the privacy of our health information and how we may use and disclose your healthinformation.We may use and disclose your medical records only for each of the following purposes:-Treatment: Providing, coordinating, or managing health care and related services by one or morehealth care providers-Payment: Such activities as obtaining reimbursement for services, confirming coverage, billing orcollection activities, and utilization review.-Health care operations: Include the business aspects of running our practice, such as conducting qualityassessment and improvement activities, auditing functions and customer service.We may contact you to provide appointment reminders or information about treatment alternatives orother health related benefits and services that may be of interest to you.Any other uses and disclosures will be made only with your written authorization. You may revoke suchauthorization in writing and we are required to honor and abide by that written request, except to theextent that we have already taken actions relying on your authorization. You have the following rightswith respect to your protected health information, which you can exercise by presenting a writtenrequest to a member of the Meditouch Clinic DMT staff.-The right to request restrictions on certain uses and disclosures of protected health information. Weare, however, not required to agree to a requested restriction. If we do agree to a restriction, we mustabide to it unless you agree in writing to remove it.-The right to reasonable requests to receive confidential communication of protected healthinformation from us by alternative means or at alternative locations.-The right to inspect and copy your protected health information.-The right to amend your protected health information-The right to receive an accounting of disclosure of protected health information.-The right to request a copy of our current Notice of Privacy Practices at any time.If you feel that your rights to privacy have been violated, you may file a complaint with this office or withthe Secretary of the Department of Health and Human Services. All complaints must be submitted inwriting.I have read and understand the above Notice of Privacy Practices and understand that anyinformation regarding my health care may be used for the purposes listed above. I also understandmy rights as outlined above.Signature of Patient/Guardian: Date:For the treatment of minors: I hereby grant permission for Occupational Therapy/ Physical Therapy tobe performed on this minor.Patient Signature: Date:Once completed, please save and return via email to jrp@meditc.org
I hereby give my consent for the authorized personnel at Diversified Movement Therapy Meditouch Clinic to evaluate me and render subsequent treatment in accordance with the plan of care authorized by the therapist and/or physician. I authorize release of any medical information to my physician and therapist as needed to evaluate and treat me.
