Patient Registration I am registering* Myself A Child / Dependent Patient Name* First Middle Last Address* 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 Phone (Home)*Phone (Work)Phone (Cell)Birth Date* Age*Sex* Male Female Other Social Security Number*Email EmployerMarital Status*SingleMarriedDivorcedSpouse's Name* First Last Reason for VisitReferralLast Physician Visit Emergency Contact Name* First Last Relationship*Emergency Contact Phone*Responsible Party / Guardian* First Last Relationship*Date of Birth* Phone*Social Security Number*EmployerWhy was Nash Rehab your choice?FriendDoctorRadio AdInternetFacebookNashrehab.comPlease contact me by email for upcoming appointmentsYesNoInsuranceMedicare (New West, BCBS, etc.)MedicaidWorker's CompBlue Cross Blue ShieldCignaAllegiance (State Plan)Allegiance (Non-State Plan)Tricare/VAClaim #Date of Injury Assignment and Release I hereby authorize my insurance benefits to be paid directly to Nash Spine and Joint Rehabilitation (NSJR) and for NSJR to release an information required by the insurer for said payments. I am financially responsible for non-covered services and for providing current insurance information. Supplies are considered a "cash" sale and will not be billed to insurance. We will provide you with a detailed receipt to use for flex accounts, tax purposes or possible insurance payers. A detailed explanation of the advanced beneficiary notice is available at the front office. NSJR has the right to accept photographs and to take photographs, videotape or digital recordings of me and use these exclusively for the purpose of my care. I authorize NSJR to access any part of my records from my physician's office for continuity of care and/or for the adjudication of all claims relating to payment of services. My medical records will be held in strict confidence and will not be released to any other party without my expressed written authorization. I hereby consent to receive physical therapy treatment at NSJR starting today and terminating when determined by myself, my physician, or my physical therapist. I have read this information and understand its content.Notice of Privacy Practices Summary This notice is a summary of how your protected health information is used and disclosed and how you can obtain access to this information. Please see the front desk to review/obtain a full copy of our Notice of Privacy Practices. Uses and Disclosures of Health Information We use health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive. We may use or disclose identifiable health information about you without your authorization for several other reasons. Subject to certain requirements, we may give out health information without your authorization for public health purposes, for auditing purposes, for research studies, and for emergencies. We provide information when otherwise required by law, such as for law enforcement in specific circumstances. In any other situation, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and disclosures. We may change our policies at any time. Before we make a significant change in our policies, we will change our notice and post the new notice in the waiting area and in each examination room. You can also request a copy of our notice at any time. For more information about our privacy practices, contact the person listed below. Your Rights Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to: Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522 Obtain a paper copy of the notice of privacy practices upon request Inspect and obtain a copy of your health record as provided for in 45 CFR 164.524 Amend your health record as provided in 45 CFR 164.528 Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528 Request communications of your health information by alternative means or at alternative locations Revoke your authorization to use or disclose health information except to the extent that action has already been taken Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights. Complaints If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the person listed below. You also may send a written complaint to the U.S. Department of Health and Human Services. The person listed below can provide you with the appropriate address upon request. Our Legal Duty We are required by law to protect the privacy of your information, provide this notice about our information practices, and follow the information practices that are described in this notice. If you have any questions or complaints, please contact: Anna Nash, PT, MDT at Nash Spine and Joint Rehab, 2748 Colonial Drive, Suite A Helena, MT 59601. Fax: 406-443-1144 WRITTEN ACKNOWLEDGEMENT I acknowledge that I have reviewed the Notice of Privacy Practices which provides a description of information uses and disclosures. I understand that I have the right to request restrictions as to how my health information may be used or disclosed and that the organization is not required to agree to the restrictions I request. Signature*Date* NameThis field is for validation purposes and should be left unchanged.