Patient Registration HIPAA Certification Seal Step 1 of 520%Location*Select OneAshburn / BroadlandsBrambleton / AshburnCentrevilleFairfax / BurkeFairfax / MerrifieldHerndon / Elden St.Herndon / WorldgateLeesburgLortonManassasMiddleburgOaktonOld TownPotomac Falls / SterlingShirlingtonSkylineSpringfield / FranconiaStone Ridge / South RidingTysonsWelcome and thank you for selecting The Jackson Clinics for your physical therapy care. Our mission is to offer you the highest quality care in a comfortable, efficient and safe manner. Listed below are some guidelines for your review. Throughout the time you receive services from our organization, please feel free to contact any member of our team with questions or if you need any information. Wishing you good health, The Jackson Clinics * Primary Care Referrals: Please obtain all of the necessary referral forms (if required by your insurance) from your primary care physician in advance of your visit. * Co-Payments: Co-payments must be paid upon the patient's arrival. We accept check and most major credit/debit cards. * Non-covered services: Supplies and equipment must be paid for at the time of service. * Attire for Physical Therapy: Shorts or sweatpants with an elastic waistband may be ideal, particularly if we are treating the lower extremities. Loose-fitting clothing is recommended for treatment of the upper extremities. * Tardiness: Please call if you are running late. Physical therapy treatments may be abbreviated for patients arriving 10-15 minutes late. Patients arriving more than 15 minutes late may be asked to reschedule. Obviously, we try to deliver the same respect for your time – if we are running late, the session will be completed in its entirety. * Appointment/Cancellation Policy: I understand that physical therapy has been prescribed for me and that physical therapy is an ongoing process which requires regular attendance to be optimally effective. I understand that if I am late for my appointment, I may be given the opportunity to reschedule my appointment or to accept an abbreviated treatment for that day. I understand that if I cancel or no show for three cumulative appointments, The Jackson Clinics may discharge me from care for being non compliant. * I have read and understand the above guidelines. Patient InformationCase IDTitleMr.Mrs.MissMs.Name* First Last Is this your legal name?YesNoMy legal name isMarital StatusSingleMarriedSeparatedDivorcedWidowedSexMaleFemaleDate of Birth* Date Format: MM slash DD slash YYYY Contact InformationAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred Phone Number*Referring PhysicianDate of Onset/problem Date Format: MM slash DD slash YYYY OccupationEmployerEmployer Phone NumberHow did you hear about us?*Doctor RecommendationFamily/Friend RecommendationInsurance PlanGoogleYelpFacebookInstagramReturning PatientGym MemberPersonal TrainerMay we contact you via email?YesNoif yes, email address:* Insurance InformationIs this patient covered by insurance?*YesNoName of Primary Insurance*Subscriber's Name*Subscriber's Date of Birth* Date Format: MM slash DD slash YYYY Group Number*Policy Number*Patient's Relationship to Subscriber*SelfSpouseChildOther relationshipOtherSecondary InsuranceIs the patient covered by a secondary Insurance?YesNoName of Secondary Insurance (if applicale)*Subscriber's Name*Group Number*Policy Number*Person Responsible for BillName of Person Responsible for Bill*Date of Birth Date Format: MM slash DD slash YYYY Patient's Relationship to Responsible Party*SelfSpouseChildOther relationshipAddress (if different) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone NumberOccupationEmployerEmployer Street Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Employer Phone NumberLawyerDo you have an attorney for this injury?YesNoWere you in an auto accidentYesNoIf so, please provide the following informationAttorney's NameAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Attorney's Phone NumberIn Case of EmergencyName of Local Friend or Relative*Relationship to Patient*Preferred Phone Number*The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to The Jackson Clinics, LP. I understand that I am financially responsible for any balance. I also authorize The Jackson Clinics, LP or insurance company to release any information required to process my claims. I consent to rehabilitation and related services as per the plan of care. In doing so, I understand, acknowledge and affirm that such rehabilitation and related services may involve bodily contact, touch and/or direct contact of a sensitive nature.* Confirm THE JACKSON CLINICS, LP EFFECTIVE DATE APRIL 4, 2005 THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. Please review the full Notice of Privacy Practices (NPP). If you have any questions about this notice, please contact Anna Jackson our Privacy Official at (540)687-8181. WHO WILL FOLLOW THIS NOTICE: This notice describes our privacy practices. We are affiliated with and in some circumstances may operate under the policies and practices of: The Jackson Clinics, LP - Ashburn/Broadlands The Jackson Clinics, LP - Brambleton/Ashburn The Jackson Clinics, LP - Centreville The Jackson Clinics, LP - Fairfax/Burke The Jackson Clinics, LP - Fairfax/Merrifield The Jackson Clinics, LP - Franconia The Jackson Clinics, LP - Herndon The Jackson Clinics, LP - Leesburg The Jackson Clinics, LP - Lorton The Jackson Clinics, LP - Manassas The Jackson Clinics, LP - Middleburg The Jackson Clinics, LP - Oakton The Jackson Clinics, LP - Old Town/Alexandria The Jackson Clinics, LP - Potomac Falls/Sterling The Jackson Clinics, LP - Shirlington/Arlington The Jackson Clinics, LP - Skyline/Falls Church The Jackson Clinics, LP - Stone Ridge/South Riding The Jackson Clinics, LP - Tyson The Jackson Clinics, LP - Worldgate/Herndon All these entities, sites, and locations follow the terms of this notice. In addition, these entities, sites, and locations may share health information with each other for treatment, payment, or health care operations purposes described in this notice. OUR PLEDGE REGARDING HEALTH INFORMATION: We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this health care practice, whether made by your personal physical therapist or others working in this office. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information. We are required by law to: make sure that health information that identifies you is kept private; give you this notice of our legal duties and privacy practices with respect to health information about you; and follow the terms of the notice that is currently in effect. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU. The following categories describe different ways that we use and disclose health information. By coming for care, you give us the right to use your information for treatment, to get reimbursed for your care, and to operate our organization. There are also various other ways in which we may use or disclose your information: Appointment Reminders To Allow Oversight of the Quality of the Healthcare We Provide To Allow Workers’ Compensation Claims As Required by Subpoena in Lawsuits and Disputes Various Uses as Required by Law or to Avert a Serious Threat to Health or Safety The full details for all these uses are contained in the full NPP. YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU. You have the following rights regarding health information we maintain about you: Right to Inspect and Copy Right to Amend Right to and Accounting of Disclosures Right to Request Restrictions Right to Request Confidential Communications Right to a Paper Copy of This Notice Information on how to exercise these rights can be seen in the NPP or can be obtained from Richard Jackson, PT, OCS, Physical Therapist/Privacy Official at (540)687-8181. CHANGES TO THIS NOTICE We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our facility. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register for treatment or health care services, we will offer you a copy of the current notice in effect. COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact Richard Jackson, PT, OCS, Physical Therapist/Privacy Official. All complaints must b e submitted in writing. You will not be penalized for filing a complaint. OTHER USES OF HEALTH INFORMATION Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.* I have read the Notice of Privacy Practices from The Jackson Clinics.Discussion of Treatment/Medical InformationIf you are accompanied to your physical therapy session(s) is it acceptable to discuss your medical information with the individual(s) present?*YesNoIs there any individual, besides your doctor and involved health care practitioner(s), with whom The Jackson Clinics has permission to discuss your treatment plan/medical information? If yes, please provide individual's name.Spouse/Significant OtherConsentYesNoNameSon/DaughterConsentYesNoNameSon-in-law/Daughter-in-lawConsentYesNoNameFriendConsentYesNoNameOtherConsentYesNoNameStudent InvolvementThe Jackson Clinics is actively involved in the education of Doctoral Students in Physical Therapy as well as Athletic Training Students and others. These students may be involved in your care in ways which may involve review of personal health information, discussion and observation, and execution of care procedures as directed/supervised by the mentor.Please indicate below which of the following learners may participate in your care:I grant permission to Doctor of Physical Therapy Students*YesNoI grant permission to Athletic Training/Exercise Science Students*YesNoI grant permission to Volunteer Observers*YesNoPlace of TreatmentTo facilitate your care, a portion of your treatment may take place in the open gym area of our clinic. Do you agree to this?*YesNoBriefly describe the history of your current condition:*List of medications you are currently taking:We encourage you to bring a list with youName of MedicationDosageAmountHow OftenName of MedicationDosageAmountHow OftenName of MedicationDosageAmountHow OftenEnter Over the Counter Medications (Please separate each item with a comma)WEAR GLASSES / CONTACTS?*YesNoHAVE YOU FALLEN IN THE PAST YEAR?*YesNoIF YES, HOW MANY TIMES:*IF YES TO FALLING, DID YOU SUSTAIN AN INJURY AS RESULT OF THE FALL?*YesNoDO YOU CURRENTLY HAVE ANY “FLU TYPE” SYMPTOMS (I.E. FEVER, COUGHING)?*YesNoIF YES, WHAT SYMPTOMS:DO YOU HAVE ANY OPEN CUTS, LESIONS OR WOUNDS?*YesNoIF YES, WHERE: Financial Policy StatementWe would like to thank you for choosing The Jackson Clinics, LP and allowing us to provide your healthcare needs. The policies listed herein have been approved by the management with the goal of providing the finest care and service to our patients at the least cost. Care delivered by this facility will be administered regardless of race, color, creed, social status, national origin, handicap or gender. We are committed to providing you with the best possible care. In order to accomplish this, we need your assistance in reading and understanding financial responsibility and our payment policy. RESPONSIBILITY FOR THE BILL It is the expectation that all patients/guarantors receiving services are financially responsible for the timely payment of the charges incurred. While the clinic will file verified insurance for payment of the bill(s) as a courtesy to the patient, the patient/guarantor is ultimately responsible for payment and agrees to pay the account(s) in accordance with the regular rates and terms of the clinic in effect at the present time. POINT OF SERVICE COLLECTIONS Payment for service is due at the time to service(s) is rendered and non-emergency services may be declined until the necessary payment arrangements have been accomplished. Payment will be accepted in checks and most major credit/debit cards. We will be happy to file verified insurance on your behalf. For your convenience if your check is dishonored or returned for any reason, we will electronically debit your account for the amount of the check plus a processing fee of $50.00. Patients unable to comply with the Point-of-Service payment policy will be referred to the administrative office for necessary arrangements. PAYMENT ARRANGEMENTS The clinic will make a reasonable effort to assist patients in meeting their financial obligations. Financial arrangement for payments will be made at the clinic’s discretion, based on the amount of the patient’s liability and the patient’s ability to pay based on a completed credit application. PATIENT SCHEDULING Every effort will be made to schedule the patient at the patient’s convenience. Patients will be advised of the clinic payment policy at the time appointments are made along with the best estimate of the cost of the office visit. ACCEPTANCE OF INSURANCE The clinic will accept "Assignment of Benefits" on verified insurance policies and submit a bill to the carrier on the patient’s behalf. It is understood that insurance is filed as a courtesy to the patient and does not relieve the patient of financial responsibility. Claims filed will be held 45 days pending payment. The patient/guarantor will be responsible for payment in full on all the claims not paid within the allowed period of time. VERIFICATION OF INSURANCE Because of the wide range of insurance plans in effect, the clinic will verify insurance coverage, deductibles and other limits, prior to acceptance for payment of services. PRE-CERTIFICATION The clinic will make every effort to pre-certify all services, provided the clinic is supplied with the necessary information. REJECTED CLAIMS Our staff is trained to assist you with insurance questions. COVERAGE ISSUES can only be addressed by your employer or group health administrator. Although our assistance is available, we cannot act as a mediator on your behalf. RELEASE OF INFORMATION By signing our release of information form, you provide us with the authority to release such information as is necessary to collect from insurance companies and other third party payers. PATIENT RESPONSIBILITY Balances after insurance are due within 30 days of the insurance payment, unless other satisfactory arrangements have been made with the clinic. Not all services are covered by all insurance companies. It should be understood that by accepting the service(s), the patient is responsible for payment regardless of the fact that insurance covers the service or not. The clinic cannot become involved with any third party liability matters and must always look to the patient/guarantor for payment of the bill. OUTSTANDING BILLS The clinic reserves the right to request deposits and payments for outstanding balances. Deposits will be based on the outstanding balance plus the patient’s share of the bill for the new services to be performed. HEALTHCARE LIENS The clinic reserves the right to file healthcare liens against the patient and other responsible parties as is deemed appropriate to protect the clinic interest. BAD DEBTS/LEGAL ACTION If the account is not paid in full or satisfactory arrangements made within the allowable time frame, the clinic reserves the right to refer the account to an attorney and/or a collection agency for collection of the balance. I agree to assume responsibility for all charges incurred should collections of this balance become necessary including court costs and attorney’s fee. The administrative and management welcomes the opportunity to discuss any aspect of the financial policy. We appreciate your confidence and strive to provide quality healthcare. In the event that The Jackson Clinics must file a law suit to collect a debt, I agree the jurisdiction shall be in the courts of Loudoun County, VA.* I have read and understand the Financial Policy/Policy Statement above.