PERSONAL STATEMENT
Please Provide a detailed description of how the accident took place. Including Hospitals or Urgent Care’s you went to and the dates. Sign and date on the bottom.
Patient Information
Street
City
State
Zip Code
General Information
How were you injured? (mark one)
After Accident Information:
Medical Care After Injury:
Health History:
Previous Injuries:
Later Symptoms: (Please note any symptoms that started AFTER the injury occurred)
HEAD
NECK
SHOULDERS
ARMS AND HANDS
CHEST
ABDOMEN
MID BACK
LOWER BACK
HIPS, LEGS AND FEET
GENERAL
INFORMED CONSENT TO MEDICAL TREATMENT
I hereby consent to and authorize medical care and treatment as my physician, assistants or designees may deem
necessary or advisable. This care may include, but is not limited to, medical evaluations/examinations, physical
therapy evaluations/examinations, physical therapy treatment/modalities, chiropractic care and/or administration of
injectable medications (for pain relief) of my condition(s) by licensed medical doctors, physical therapists and
chiropractors at ADVANCED THERAPEUTIS SPECIALISTS (DBA) COMPREHENSIVE INJURY CENTERS
also known as medical providers. I understand that my care is directed by my physician and that other personnel may
render care and services to me according to my physician’s instructions.
Cooperation with Appointments: I must come to scheduled appointments unless there are unusual circumstances.
I understand and agree to cooperate with my physician and perform the physical therapy treatment/exercises and/or
chiropractic adjustments intended for me as prescribed by my physician. If I have trouble with any part of my
treatment program, I will discuss it with my therapist or physician.
No guarantee: I understand that there are no guarantees regarding a cure for or improvement in my condition. I
understand that my medical providers will outline and discuss goals of physical therapy treatment for my condition
and will discuss treatment options, including chiropractic adjustments, medications and/or injections with me before
I consent to treatment.
Informed consent for treatment: The term “informed consent” means that the potential risks, benefits and
alternatives of physical therapy treatment, chiropractic adjustments, medications and injections have been explained
to me. The medical providers offer 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.
Potential risks: I may experience an increase in my current level of pain or discomfort or an aggravation of my
existing injury or condition(s). This discomfort is usually temporary; if it does not subside in a reasonable time
period, I agree to contact my physical therapist or physician.
Potential benefits: I may experience an improvement in my symptoms and an increase in my ability to perform my
work duties and daily activities. I may experience increase 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.
Alternatives: If I do not wish to participate in the treatment plan and/or physical therapy program, I will discuss my
medical, surgical or pharmacological alternatives with my physical therapist, as well as my physician.
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.
MEDICAL RECORDS AUTHORIZATION FORM
Patient Information (Please Print)
FOR HOSPITAL/URGENT CARE
indicated below to/from:
Requested Information:
Please send the requested information to: OWCPPT@GMAIL.COM or (833) 478-4878
Your Rights: You may refuse to sign this authorization. Your refusal will not affect your ability to obtain treatment or payment.
- If the persons or entities authorized to receive this information are not health care providers or health plans covered by federal health privacy laws, they may
re-disclose the information and those laws would no longer protect the disclosed health information. - Once you sign this authorization, we can rely on it until you revoke it or, if you have not revoked it, until it expires. You can revoke this authorization by mailing a signed and dated letter to
Advanced Therapeutic Specialists
DBA Comprehensive Injury
Centers
1548 SW 5th Ave.
Boca Raton, FL 33432
1925 Cordova Rd. Fort
Lauderdale, FL 33316
14590 S. Military Trail E-10
Delray Beach, FL. 33484
3. The information authorized for release may include sensitive records which may include, but are not limited to Sexually Transmitted Diseases (STDs), the
human immunodeficiency virus (HIV), also known as Acquired Immune Deficiency Syndrome (AIDS), substance abuse, drug use and/or mental health information
PATIENTS RESPONSIBILITIES (Please initial each item)
APPOINTMENT AND STATUS
1. I will inform the Front Desk staff if my address, phone number, employment and/or
employment position changes.
2. I will keep appointments and if I cannot make my appointment, I will contact the Front Desk staff
with at least 24 hours’ notice.
3. I understand that I can contact the Front Desk staff regarding any appointment issues, MRI referrals,
specialist referrals and related paperwork.
4. I understand that I can request to make an appointment with a Claims Manager to discuss issues
regarding my case status, denial, denial of authorization for treatment and/or if I have a new injury.
5. I am responsible for scheduling my treatment appointments for at least 3 weeks in advance to assure
appointment time slot(s) I need.
6. I understand that I need to leave a voicemail message if I want a callback if the office is closed or if I am
greeted by the answering machine.
7. I understand that I cannot tell my doctor to put me off work unless he says it is medically necessary
CLAIM STATUS
8. I will forward or bring a copy of any correspondence I receive from OWCP/Department of Labor, even after I
am discharged or no longer attending therapy at Comprehensive Injury Centers.
9. I understand that failure to comply with forwarding correspondence can result in a denial of my claim and if my
claim is denied for not bringing documents on time, I will be financially responsible for the services I have
received.
10. I understand that I need to comply with the prescribed therapy and my doctor’s instructions in order to
achieve maximum results and return to pre-injury status
FORMS
11. I am responsible for all documents pertaining to my wages, loss time. Mileage reimbursement, medical
expense reimbursement and form submissions such as CA-7s to my agency. My provider’s office will not
engage in matters regarding my wages, pay or related documents. We will not fax any documents to
agencies or OWCP.
PRIVACY
12. I will respect the privacy of others especially of my co-workers by not mentioning to others that I
have seen someone here at comprehensive injury centers nor anything of that nature.
MEDICAL RELEASE AND ASSIGNMENT OF BENEFITS
RELEASE AUTHORIZATION Advanced Therapeutic Specialists/ DBA Comprehensive Injury Centers TO ENDORSE CHECKS
AND/OR TO SIGN ANY PIECE OF PAPER WHICH WILLENHANCE OR EXPEDITE PAYMENT TO THE PROVIDER FOR SERVICES
RENDERED, INCLUDING BUT NOT LIMITED TO A RELEASE OF MEDICAL RECORDS and ASSIGNMENT OF
BENEFITS/AUTHORIZATION TO PAY.
Know by all these present that: The undersigned has made, constituted and appointed, and by these presents does herby make, constitute and
appoint Advanced Therapeutic Specialists/ DBA Comprehensive Injury Centers, and any of its duly authorized agents and employees as and
to be the undersigned’s true and lawful attorney for and in the undersigned’s name, place and stead to endorse any and all checks, drafts or money
orders which are made payable to the undersigned alone or to the undersigned and the said Advanced Therapeutic Specialists/ DBA
Comprehensive Injury Centers, which checks, drafts or money orders are made payable for services which have been made by Advanced
Therapeutic Specialists/ DBA Comprehensive Injury Centers., at the request or with the knowledge and approval of the undersigned and/or the
maker of the check, draft of money order.
Furthermore, the undersigned allows Advanced Therapeutic Specialists/ DBA Comprehensive Injury Centers., or any of its agents to
sign any paper that will be necessary to enhance, expedite and/or allow payment to said provider. This may include affidavits of non-
ownership of vehicles, insurance forms and other statements.
The undersigned by these presents does give and grant the said Advanced Therapeutic Specialists/ DBA Comprehensive Injury Centers
as the attorney the full power and authority to do and perform all and every act whatsoever requisite and necessary to be done in and
about the premises as fully to all intents and purposes as the undersigned might or could do to personally present insofar as the
endorsing and cashing of said checks are concerned as well as any other document.
MEDICAL RELEASE
A photocopy of this document shall be sufficient to authorize any person having records of medical treatment, services, or
supplies pertaining to me to release true copies of same to Advanced Therapeutic Specialists/ DBA Comprehensive Injury
Centers or any insurer providing coverage to mi in connection with the processing of any claim for benefits made by me or by
the assignee herein. A photocopy of this document shall be as binding as an original signature page.
The undersigned does hereby ratify and confirm any and all actions taken by the said attorney in accordance with this special
power and which the said attorney shall do or cause to be done by virtue of their presence. to make medical benefits
payments otherwise payable to me for services rendered by Advanced Therapeutic Specialists/ DBA Comprehensive Injury
Centers, but not to exceed the charges of those services, payable to and mailed to:
AS S I GNM E NT OF B E NE F I T S
I hereby instruct the insurance carrier that in the event the subject medical benefits are disputed for any reason, including medical
reasonableness and/or necessity the amount of unpaid benefits claimed by Advanced Therapeutic Specialists/ DBA Comprehensive Injury
Centers is to be set aside, and not disbursed until the dispute is resolved. Furthermore, I hereby irrevocably assign to Advanced Therapeutic
Specialists/ DBA Comprehensive Injury Centers the rights and benefits and any and all causes of action resulting from nonpayment under any
policy of insurance, indemnity agreement, or any other collateral source as defined in Florida Statutes for any service and or charges provided
by Advanced Therapeutic Specialists/ DBA Comprehensive Injury Centers
Notice of Privacy Practices
YOU DO NOT NEED TO RESPOND TO THIS NOTICE
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS
TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY
AHCA’S Responsibilities
The Agency for Health Care is required by law to maintain the privacy of your protected health information in our custody. We must provide you with notice of our legal duties and privacy practices with respect to your health information. We must also follow the terms of this notice.
How AHCA Uses and Safeguards your Health Information
If you are a Medicaid/MediKids recipient, we use your health information to pay for your health services and to operate the Medicaid program. We may also use
your health information to tell you about treatment alternatives or other health-related benefits and services.
The following are some examples of how we may use your health information:
Your doctor may send us a claim to pay. The claim includes information that identifies you and the type of care you received. We may share your information with a company that
reviews hospital records to check on the quality of care that you received. We may send appointment reminders for Child Health Check-Up services. AHCA may also use and
disclose your health information as permitted by law, such as:
To entities outside the agency for purposes directly connected with the administration of the State Medicaid plan.
In responding to public emergencies, access to your health information may be granted to persons or agency representatives who are subject to standards of confidentiality comparable
to those of AHCA. Such other agencies may include the Federal Emergency Management Agency (FEMA) or the Centers for Disease Control (CDC).
Where disclosure would assist in determining eligibility for benefits, amount of medical assistance payment or otherwise assists the agency in the administration of the Medicaid
program.
To the confidential Florida abuse hotline in order to report abuse, neglect and/or domestic violence as per criteria and conditions imposed on the agency by law.
For health oversight activities and/or administration of the Medicaid program, such as inspections, investigations, and audits. To conduct research to benefit the Medicaid program.
For purposes of treatment, payment, or our operations and as otherwise required by law.
Other uses or disclosures of your protected health information require your or your personal representative’s written authorization. For example, we will not use or disclose
psychotherapy notes without your writtenauthorization or as allowed by law. We will not use or discloseyour protected healthinformationfor marketing purposes without your written
authorization and we will not sell your protected health information without your written authorization. We also are prohibited by law from using or disclosing genetic information for
insurance underwriting purposes. At any time, you may revoke authorizations in writing. If you cannot give your authorization due to an emergency, we may release your health
information if it is in your best interest
You have the following rights with respect to your protected health information:
To see or obtain a copy of your health information that is maintained by AHCA. We may not be able to provide health information that includes psychotherapy notes, is part
of a legal case, or is otherwise excluded from disclosure by law. We may charge a copying fee.
To request that we amend health information we maintain that you believe is incorrect or incomplete
To request a list of disclosures we have made of your health information. The list may not include disclosures authorized by you, disclosures for treatment, payment and health care
operations, or other disclosures permitted by law.
To request that we contact you at a different address or phone number, if contacting you about your health information at your present location would endanger you. To
request that we limit the use and disclosure of your health information. We are not required to agree to your request. To request another paper copy of this notice.
To opt-out of fundraising communications from us should the agency ever engage in fundraising. To receive a notification from us following a breach of your unsecured protected
health information
Contact Information
If you have any questions, wish to make a request regarding your health information, or would like another paper copy of this notice, please contact the AHCA Medicaid
office in your area at the telephone number listed below. We may ask you to make the request in writing
FILING A HIPPA COMPLAINT
If you believe your privacy rights have been violated by AHCA or one of its employees, you may file a complaint with AHCA and/or the Secretary of the Department of Health
and Human Services at the addresses below. You will not be retaliated against for filing a complaint.
Privacy Officer Secretary
Agency for Health Care Administration Department of Health and HumanServices
2727 Mahan Drive, Mail Stop 4 200 Independence Ave.SW
Tallahassee, Florida 32308 Washington, D.C. 20201
(850) 412-3960 (800) 368-1019
Future Changes to the Notice of Privacy Practices
AHCA reserves the right to change the terms of this notice and to make new notice provisions effective for all protected health information that we maintain. If we make a material
revision to this notice, we will send a revised copy of the notice to recipient households within sixty (60) days of the revision.
Who receives the Notice of Privacy Practices?
We send this notice to every recipient household. This notice applies to all Florida Medicaid recipients.
I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read them or declined the opportunity to read them and understand them. I understand
that this form will be placed in my patient chart and maintained for six (6) years.
ELECTRONIC COMMUNICATION CONSENT FORM
You have the option of sending and receiving electronic communication to and from Fed-Hurt and for
attending sessions remotely (over-the-phone or via tele-health (video)). Fed-Hurt would like to ensure
that you understand the risks, benefits, limitations, and requirements of using electronic
communication (including tele-health). Information gathered from electronic communication with
your provider may be used for diagnosis, treatment, therapy, follow-up and/or education.
I understand that:
- The use of electronic communication that involves information being sent, received, or
stored electronically carries a level of security risk. Comprehensive Injury Centers recommends,
and in some cases requires, the use of secure (encrypted) forms of communication to minimize
the security risk, though I understand that this does not always guarantee or eliminate the risk
of a potential breach of information. - Without electronic consent, communication and continuum of care may be delayed and
interrupted for client and their providers. - These communications may include appointment reminders, test results, treatment
updates, surveys, and other important information related to my care. Since text messages do
not meet privacy standards, they cannot include private health information. Please leave any
clinical details in a voicemail or wait to have a direct conversation with the provider.
By signing or providing verbal consent of this form, I acknowledge that I have read, understood,
and have discussed with my provider the risks, benefits, and limitations of each form of electronic
communication.