DATE *

MM

DD

YYYY

CHOOSE ONE *

MINOR

SINGLE

MARRIED

DIVORCED

WIDOW

OTHER

NAME *

First Name

Last Name

ADDRESS *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

HOME PHONE

(###)

###

####

WORK PHONE

(###)

###

####

CELL PHONE *

(###)

###

####

HOW DID YOU HEAR ABOUT US? *

Doctor

Family/Friend

Directory/Yellow Pages/Yelp

Previous Client

Other/Walk In

EMERGENCY CONTACT *

First Name

Last Name

EMERGENCY CONTACT PHONE *

(###)

###

####

PRIMARY INSURANCE ADDRESS

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

PRIMARY INSURANCE PHONE

(###)

###

####

FINANCIAL ACKNOWLEDGMENT *

Please check each box below to indicate you have read, understand, and agree to follow our financial/payment policy.

I HEREBY AUTHORIZE PAYMENT DIRECTLY TO MY PROVIDER FOR ALL INSURANCE BENEFITS OTHERWISE PAYABLE TO ME FOR MEDICAL SERVICES RENDERED.

I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES NOT ALLOWED, OR PAID FOR BY MY INSURANCE AND FOR ALL SERVICES RENDERED ON BEHALF OF MYSELF OR MY DEPENDENTS.

I UNDERSTAND THAT IT IS MY FINANCIAL RESPONSIBILITY TO KNOW WHEN MAXIMUM INSURANCE BENEFITS HAVE BEEN MET.

I AUTHORIZE MY PROVIDER TO RELEASE THE INFORMATION REQUIRED TO SECURE PAYMENT OF BENEFITS.

I AUTHORIZE THE USE OF MY SIGNATURE ON ALL INSURANCE SUBMISSIONS.

CONSENT FOR TESTING AND TREATMENT *

Please check each box below to indicate you have read, understand, and agree to our policy for testing and treatment protocols.

I HEREBY AUTHORIZE THE THERAPIST, REHABILITATION WORKERS, AND EMPLOYEES OF NORTHWEST WORK OPTIONS, INC AND PERSONS AUTHORIZED BY SUCH OTHER INSTITUTIONS AS MAY BE REQUESTED BY NORTHWEST WORK OPTIONS TO CARRY OUT EXAMINATIONS, TESTING PROCEDURES, AND TREATMENTS DEEMED NECESSARY AND ADVISABLE.

I UNDERSTAND I AM ABLE TO STOP THE EVALUATION OR TREATMENT AT ANY TIME AND FOR ANY REASON.

I UNDERSTAND THAT STOPPING THE EVALUATION OR TREATMENT WITHOUT GOOD REASON MAY AFFECT THE STATUS OF MY CLAIM, OR EVEN RESULT IN CLAIM CLOSURE.

I UNDERSTAND IF I HAVE ANY QUESTIONS ABOUT THE EXAMINATION OR TREATMENT, OR ANY OTHER PORTION, I AM TO ASK STAFF.

I UNDERSTAND THAT I WILL BE PERFORMING MOVEMENTS AND WORK RELATED TASKS THAT MAY CAUSE AN INCREASE IN PAIN.

I UNDERSTAND AND GIVE PERMISSION FOR THE COLLECTION AND DISTRIBUTION OF VOCATIONAL OR MEDICAL INFORMATION RELATED TO THIS EVALUATION/CASE TO ALL INVOLVED PARTIES AS NECESSARY FOR PAYMENT AND ASSISTING WITH RETURN TO WORK AND OTHER DECISIONS.

NOTICE OF PRIVACY PRACTICES *

Please check each box below to indicate you have read, understand, and agree with each section of the 'Notice of Privacy Practices.'

I UNDERSTAND UNDER THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996, I HAVE CERTAIN RIGHTS TO PRIVACY REGARDING MY PROTECTED HEALTH INFORMATION.

I UNDERSTAND THIS INFORMATION CAN BE USED TO CONDUCT, PLAN, AND DIRECT MY TREATMENT, OBTAIN PAYMENT, IN ADDITION TO BEING UTILIZED DURING THE COURSE OF NORMAL HEALTHCARE OPERATIONS SUCH AS QUALITY ASSESSMENTS AND PROVIDER CERTIFICATIONS.

I ACKNOWLEDGE I CAN REQUEST A NOTICE OF PRIVACY PRACTICES CONTAINING A MORE COMPLETE DESCRIPTION OF THE USES AND DISCLOSURES OF MY HEALTH INFORMATION.

I UNDERSTAND THAT THIS ORGANIZATION HAS THE RIGHT TO CHANGE ITS NOTICE OF PRIVACY PRACTICES FROM TIME TO TIME.

I UNDERSTAND THAT I MAY REQUEST IN WRITING THAT NORTHWEST WORK OPTIONS INC. RESTRICT HOW MY PRIVATE INFORMATION IS USED OR DISCLOSED.

I UNDERSTAND THAT NORTHWEST WORK OPTIONS INC. IS NOT REQUIRED TO AGREE TO MY REQUESTED RESTRICTIONS.

N0-SHOW POLICY

It is the policy of Northwest Work Options, Inc. that if a client does not attend a scheduled appointment or evaluation, he or she will incur the following charges or fees. By checking each box below, I acknowledge to have read, understand, and agree to the NO-SHOW POLICY as stated.

NO SHOW/LATE CANCELLATION FEE FOR THERAPY APPOINTMENT $100.00

NO SHOW/LATE CANCELLATION FEE FOR MASSAGE THERAPY $100.00

NO SHOW FEE FOR FCE APPOINTMENT $2500 IF LESS THAN 72 HOUR NOTICE IS GIVEN

NO SHOW FEE FOR WORK CONDITIONING APPOINTMENT $750

NO SHOW FEE FOR WORK HARDENING APPOINTMENT $1000

IT IS MY SOLE RESPONSIBILITY TO PAY THE AFOREMENTIONED FEES

I HEREBY ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THIS POLICY AS STATED ABOVE AND ALSO UNDERSTAND THAT THERE ARE NO EXCEPTIONS UNLESS APPROVED BY MANAGEMENT

SIGNATURE *

I ACKNOWLEDGE TO HAVE READ, UNDERSTAND, AND AGREE TO THE CONSENT, PRIVACY PRACTICES, AND NO-SHOW POLICY FOR NORTHWEST WORK OPTIONS, INC.

First Name

Last Name