Admission Form

Please complete this Admission Form prior to your appointment. Thank you.

Date of Birth

INFORMED CONSENT

Physical Therapy is a patient care service provided in response to a wide range of medical care needs of outpatients of all ages regardless of gender, sexual orientation, religion, color, race, creed, national origin, or disability. The purpose of physical therapy is to treat disease, injury, and disability by evaluation, examination, testing, use of rehabilitative procedures, mobilization, massage, exercises, and physical agents to aid the patient in achieving their maximum potential within their capabilities; and, to accelerate convalescence and reduce the length of the functional recovery. All procedures will be thoroughly explained to you before you are asked to perform them. You are expected to cooperate fully with the evaluation and treatment program. Because of the nature of services provided, you might be asked to disrobe. If this is necessary, your privacy, modesty and dignity will be considered at all times by the staff. Should you feel uncomfortable or embarrassed, you may refuse the procedure, stop the procedure and/or request another therapist. There are certain inherent risks with physical therapy treatments because you will be asked to exert effort and perform activities with increasing degrees of difficulty, which could cause an increase in your current level of pain or discomfort or an aggravation to your existing injury. You will be able to stop treatment if you feel any discomfort or pain. Your physical therapist will take every precaution to ensure that you are protected from any potentially hazardous situations. You will never be forced to perform any procedure you do not wish to perform. Because of the nature of the procedures performed within the clinical setting, your communication with family and friends may be restricted. Vincent Alarcon Physical Therapist, PC reserves the right to restrict visitors and outside communication at any time during your treatment sessions to ensure you receive the maximum therapeutic value from treatment.

CONSENT TO RECEIVE ELECTRONIC COMMUNICATIONS

As part of its marketing efforts, I understand that Vincent Alarcon Physical Therapist, PC distributes editorial materials to its patients and the general public through various methods including email, text message, and websites. I understand that the editorial information I receive through such methods is not a substitute for medical advice, medical recommendations, diagnosis, treatment or cures. If I have or suspect I have a medical problem, I will promptly contact a professional healthcare provider. I will never disregard professional medical advice or delay in seeking such advice based on the editorial content presented by Vincent Alarcon Physical Therapist, PC.

ACKNOWLEDGEMENT OF PRIVACY PRACTICES  (LOCATED AT BOTTOM OF PATIENT PORTAL )

I acknowledge that I have been made aware of where to locate the Notice of Privacy Practices from Vincent Alarcon Physical Therapist, PC. I authorize the practice to communicate with other healthcare providers involved in my care and to release information necessary for treatment, payment, healthcare operations, or as otherwise permitted by law, including to my insurance company or authorized representatives.

PATIENT NOTICE

As a patient of Vincent Alacon Physical Therapist, PC, you are being informed that for security purposes of the company’s employees and patients, the company conducts video surveillance and records audio of the premises and work sites.

PATIENT CONSENT

Based on the above information, I understand and agree to the conditions and information provided above and give my consent to the above authorizations. I agree to cooperate fully, to participate in all physical therapy procedures, and to comply with the plan of care as it is established. I have read and received a copy of the consent form and authorize release of medical information to appropriate third parties.

NOTICE OF PRIVACY PRACTICES

We protect the privacy of our patients’ health information and adhere to a set of internal policies established to conform to the requirements of state and federal laws. This privacy statement explains your rights, our legal duties, and our privacy practices.

DIRECT PHYSICAL THERAPY TREATMENT SERVICES

You are receiving direct physical therapy treatment services from an individual who is a physical therapist licensed by the Physical Therapy Board of California. Under California law, you may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits, whichever occurs first, after which time a physical therapist may continue providing you with physical therapy treatment services only after receiving, from a person holding a physician and surgeon’s certificate issued by the Medical Board of California or by the Osteopathic Medical Board of California, or from a person holding a certificate to practice podiatric medicine from the California Board of Podiatric Medicine and acting within his or her scope of practice, a dated signature on the physical therapist’s plan of care indicating approval of the physical therapist’s plan of care and that an in-person patient examination and evaluation was conducted by the physician and surgeon or podiatrist. (Business & Professions Code § 2620.1(4)).

SELF-PAY / NON-CONVERED SERVICES

I understand that if my insurance does not cover a service, or if I choose to receive services on a self-pay basis, I am responsible for payment at the time services are provided unless other arrangements have been made in advance. I understand that I will be informed of my financial responsibility before receiving non-covered services whenever possible.

USE OF ARTIFICIAL INTELLIGENCE (AI) FOR CLINICAL SCRIBING

To improve the quality and efficiency of your care, Vincent Alarcon Physical Therapist, PC may use Artificial Intelligence (AI) tools to assist with clinical documentation (“scribing”) during your visit.These tools may process conversations between you and your therapist solely to generate accurate clinical notes. 

AUTHORIZATION TO PAY & ASSIGNMENT OF BENEFITS

I hereby authorize my insurance benefits to be paid directly to VAPT,PC and I understand that I am financially responsible for non-covered services and any amount not paid by my insurance. I understand that VAPTPC is not a provider for MEDI-CAL services. I also authorize VAPTPC to release any information to process this claim.

OUT OF NETWORK INSURANCE REIMBURSEMENT

I understand that reimbursement from my insurance company is not guaranteed. All insurance plans have different coverage and benefits. It is my responsibility to contact my insurance company to verify my out of network therapy benefits. If my insurance provider does not reimburse for services provided by Vincent Alarcon Physical Therapist, PC, I am responsible for the full payment of services. Upon request, Vincent Alarcon Physical Therapist, PC may provide me with a monthly superbill receipt in order to submit a claim to my insurance company for reimbursement of medically necessary therapy services. I understand that it is my responsibility to submit claims to my insurance company and to follow up on the status of any claims.

Please contact WEBPT Billing, Our Dedicated billing department directly at (800-478-2778)

Please be advised that our on-site administrative and clinical office staff are unable to provide assistance with billing, insurance claims, or payment records. To ensure the security and privacy of your financial data, our local office staff does not have access to patient billing files. All financial matters are handled exclusively by our specialized Billing Team to ensure your concerns are addressed accurately and securely.

INSURANCE UPDATE POLICY

If your insurance coverage changes during your treatment, please provide our office with your new information as soon as possible. Please note that if updated insurance details are not on file, any unbilled visits will be processed as Self-Pay at a rate of $250 for Initial Evaluation/ Discharge and $150 for treatment or follow up visit.

CANCELLATION AND “NO-SHOW” POLICY

• It is important for you to attend your scheduled appointments to achieve the goals your physician and your therapist have established for you. If you must cancel a scheduled appointment, please call (559) 713-6461 as soon as possible. For your convenience, our telephones are on an automatic answering machine during off hours. The following is our policy for cancellations and “no-shows” (missed appointments without calling to cancel).

• If you cancel with notice of less than 24 hours, a $75.00 fee will be charged. For consideration of reversal of this charge with a legitimate excuse, call us at 559-713-6461, Dial 4 for Cancellation. Our Physical therapist and receptionist do not have the authority to make these decisions. 

• If you need to cancel two appointments—even with 24 hours' notice—we may need to discharge you from our clinic. Frequent cancellations disrupt the flow of your treatment plan, which was designed by your clinician based on your initial evaluation with your doctor's approval. This inconsistency will affect your plan of care. In this event, all remaining appointments will be canceled. If you wish to resume therapy later, a new evaluation will be required. Your referring doctor will be informed about the clinic's decision to discontinue the remaining PT visits due to our cancellation policy. Thank you for your understanding.

• If you “no-show” for two appointments (have not called to cancel), all remaining appointments will be deleted, a $75.00 fee will be charged for each missed appointment, you will be discharged from our clinic, and your physician will be notified.

MEDICAL RECORDS REQUEST

I understand that if I request copies of my medical records for personal use, fees for copying, preparation, and release of records may apply as permitted by applicable federal and state law. If medical records are requested by a company, organization, attorney, or other authorized third party, applicable fees may be the responsibility of the requesting party. Vincent Alarcon Physical Therapist, PC reserves the right to require payment of applicable fees before records are processed and released.

PATIENT RULES AND GUIDELINES

To help provide safe, efficient, and quality care for all patients, I understand and agree to the following:

• Arrive on time for each appointment. Patients arriving more than 15 minutes late may need to be rescheduled and may be subject to a $75 no-show fee.

• A $75 no-show fee may be charged for missed appointments without proper notice.

• Notify the office of any appointment changes or cancellations. Clinicians do not communicate with patients through their personal phone numbers.

• Repeated missed appointments or two (2) consecutive cancellations may result in discharge from therapy services.

• Attend my scheduled discharge visit unless otherwise directed by my therapist.

• Wear comfortable clothing and closed-toe athletic or supportive shoes appropriate for physical therapy.

• Only service animals, as defined by applicable law, are permitted in the clinic. Pets and emotional support animals are not permitted.

  
  

I understand these guidelines are intended to promote the safety, well-being, and efficient care of all patients and staff.

PAIN DISABILITY INDEX

Instructions:

This questionnaire helps us understand how much your chronic pain affects your everyday life. We want to know how much pain limits your ability to do the activities you normally do or how well you are able to do them. Please answer each question based on how pain affects you most of the time, not just when your pain is at its worst.

For each of the 7 activity categories, select a number from 0 to 10 that best describes how much pain interferes with that part of your life.

PAIN DISABILITY GUIDE

0 - No Disability

Meaning: Pain does not interfere with this activity. 

1–3 – Mild Disability 

Meaning: Pain causes a small amount of difficulty, but you can still do most activities.

4–6 – Moderate Disability

Meaning: Pain makes this activity more difficult and may require you to slow down or ask for help.

7–9 – Severe Disability

Meaning: Pain greatly limits your ability to do this activity. 

10 – Complete Disability

Meaning: Pain completely prevents you from doing this activity.