Home Health Intake Form

Please complete all applicable fields. Fields marked * are required. Your information is kept confidential and is used only for your care and billing.

🔒 This form is submitted securely and stored only for the use of Advanced Health Physical Therapy, Inc. Please submit it over a secure (https) connection.

Patient Information
Sex
Marital Status
Diagnosis
Insurance & Identifiers
Primary Coverage
Referring Physician
Case Manager
Medical History
Do you have any of the following? (check all that apply)
Did you have any previous therapy for this condition before?
Consent & Authorization

Please read and check each statement to agree.

Notice of Privacy Practices

Your Information. Your Rights. Our Responsibilities.

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.

Your Rights

You can get an electronic or paper copy of your medical record; ask us to correct your record; request confidential communications; ask us to limit what we use or share; get a list of those with whom we've shared information; get a copy of this privacy notice; choose someone to act for you; and file a complaint if you feel your rights are violated.

Your Choices

For certain information you can tell us your choices about what we share — for example with family or friends involved in your care, in a disaster relief situation, or for fundraising. We never share for marketing, sell your information, or share psychotherapy notes without your written permission.

Our Uses and Disclosures

We may use and share your health information to treat you, run our organization, and bill for your services. We may also share it for public health and safety, research, to comply with the law, for organ donation, with a medical examiner, for workers' compensation and law enforcement, and in response to lawsuits and legal actions.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information, to notify you promptly if a breach occurs, and to follow the duties and privacy practices described in this notice. For a full copy, contact our office. This Notice went into effect April 25, 2014. Advanced Health Physical Therapy, Inc., 200 S Andrews Avenue, Suite 504, Fort Lauderdale, Florida 33301. Tel: (954) 353-8847 · Fax: (954) 533-2852.

Signature

Typing your full name below serves as your electronic signature and certifies that the information provided is accurate.