Meredith Hoerske, OTR/L CO Lic #1866
Occupational Therapist/Hand to Shoulder Specialist
3775 Iris Ave, Ste 2 A & B Boulder, CO 80301
P: 720-760-3222 ~ F: 720-664-6504
frontrange.rehab@gmail.com 

Date______________ 
Client Information (Medicare)
PERSONAL INFORMATION
Patient Name: _____________________________________________
Birthdate:  ______________    ☐  Male   ☐ Female  
Address:__________________________   City: __________________ 
State: _____  Zip: ________           
Phone number: ________________Email: _______________________
Referred by or how did you find me: _____________________________
Are you working? If so, in what line of work:________________________
Hobbies/recreational activity:___________________________________

INSURANCE INFORMATION
Medicare #:_______________________________________________
If applicable:
Supplemental Insurance name:_________________________________
Supplemental ID #: __________________________________________

EMERGENCY INFORMATION
Emergency contact name: _________________ Relation: ___________
Phone number: ___________________

HEALTH HISTORY
Please list any current medications here:
__________________________________________________________
__________________________________________________________

Do you have or ever had any of the following conditions?(check all that apply)
[  ] Cardiac Issues 		[  ] Headaches	[  ] Fractures
[  ] Pacemaker 		[  ] Auto-immune 	[  ] Arthritis
[  ] Hepatitis			[  ] HIV +/AIDS	[  ] Stroke
[  ] Diabetes			[  ] Cancer		[  ] Anxiety/Depression/PTSD
[  ] High/Low Blood Pressure			[  ] Spinal Issues
[  ] Thyroid (hypo or hyper)

Hand dominance: Right [  ]     Left [  ]    Ambidextrous [  ]
Treatment side:     Right [  ]     Left [  ]   Bilateral [  ]  
                                                                                                                         
What is the reason for your visit and when did it start:__________________
____________________________________________________________

Have you had recent imaging related to this injury: X-ray [  ] MRI [  ] 

Results_____________________________________	

Did you have surgery related to this injury: No [  ] Yes [  ] 
Date of surgery: ___________________

If this was a result of an accident, is there an attorney involved: No [  ]  Yes [  ]  NA [  ]

Do you have allergies (latex specifically): ___________________________

Pain rating:
Rate your pain from 0-10/10: Lowest_______ Highest:_______

Therapy Goals:
Please list three goals you wish to achive in therapy that are related to function: (ie. bathing, dressing, cooking a meal, etc)

1._________________________________________________________

2._________________________________________________________

3._________________________________________________________

CONSENT TO TREAT AND HIPAA AUTHORIZATION

I, (your name)_________________________, give my therapist, Meredith Hoerske, OTR/L 'consent to treat' in regards to my treatment goals. 

I, (your name)_________________________, give my consent for my therapist, Meredith Hoerske, OTR/L, to communicate about my personal medical information or discuss my injury and status with the provided insurance adjustor, doctor and/or referring provider (chiropractor, PT, acupuncturist, etc.). HIPAA privacy laws are strictly adhered to; no information is shared with third parties without your explicit consent.
Initial:_________________

COMMUNICATION

I authorize Meredith Hoerske, OTR/L with Front Range Upper Extremity, LLC to leave messages via voice mail and communicate with me via Google platforms, email, chats via website/Square, as well as text messaging. 
								  Initial:_______________

RELEASE OF INFORMATION

I authorize (physician's name)  ______________________________ to release any of my medical records, x-rays or reports to Meredith Hoerske, OTR/L with Front Range Upper Extremity Rehab for the purpose of obtaining medical information pertaining to my treatment. I also authorize Front Range Upper Extremity Rehab to release my medical records to the above physican or physicians.   

Initial: ________________

CANCELLATION POLICY

I realize that emergencies and other scheduling conflicts arise and are sometimes unavoidable. However, advance notice allows me to fulfill my other client’s scheduling needs and keeps my business operating at is most efficient level.
A 24-hour notice is required to change or cancel an appointment. 

If you no-show or cancel day of your appointment, you will be charged the full amount of your appointment. If you contact me to cancel less than 24 hours, you will be charged a $75 cancellation fee that will be due at the time of your next scheduled appointment. Weather and emergencies are exceptions. PLEASE CALL, EMAIL OR TEXT TO CANCEL YOUR APPOINTMENT IF YOU HAVE COLD/FLU SYMPTOMS OR HAVE BEEN OR HAVE POSSIBLY BEEN EXPOSED TO COVID.
Initial:_______________ 

Assignments of Benefits

I hearby authorize Front Range Upper Extremity Rehab to furnish information to insurance carriers concerning this treatment and I hereby assign all payment for services rendered.
 Inital:________________

Financial Policy

I bill your personal insurance carrier solely as a courtesy to you. You are responsible for your bill. I require that arrangements for payment of your estimated share be made today prior to any additional treatments. If your insurance carrier does not remit payment to us within 60 days, the balance owed will be due in full from you. In the event that your insurance company requests a refund of payments made to us, you may be responsible for the amount of money refunded to your insurance company. If any payment is made directly to you by the insurance company for services billed by us, you recognize an obligation to promptly remit the payment(s) to us. If formal collections procedures become necessary you will be responsible for a penalty of 50% of the open balance to cover collections agency fees. Your insurance benefits as quoted to us by your insurance carrier have been reviewed with you. I assume no liability for any errors made by your insurance carrier in this quotation. I hereby allow Front Range Upper Extremity Rehab to leave a message with any information regarding insurance benefits. Not all services are covered in all contracts. Some insurance companies select certain services they will
not cover. These services, if applicable, are your responsibility. Supplies are not covered by Medicare and, if agreeing to purchase, will be paid at the time of issue.

Initlal:____________

Medicare Deductible & Supplemental Insurance

Your Original Medicare plan (part B) has an annual deductible of $257 in 2025. Medicare pays zero dollars on the first $257 of charges you incur for the year.  

Medicare will send your claim on to your supplemental insurance payer.  Depending on your plan, your supplemental insurance payer will pick up your deductible, but some plans do NOT cover the deductible. (Plans F and J pay deductibles).

If your supplemental insurance does not pick it up, then the balance due will be your responsibility. Flatirons Practice Management or I will contact you to redeem payment.

I understand that if my supplemental insurance does not cover my Medicare part B deductible of $257, I will be responsible and agree to pay it.

IF YOU RECEIVE A BILL FROM FLATIRONS PRACTICE MANAGEMENT, PLEASE CALL ME AT 720-760-3222.

Initlal:____________

Have you had Occupational Therapy services with another provider in this calander year? NO ______  YES______. 
If yes, please provide who you saw, for what condition and how many visits. ________________________________________

Student Shadowing

Are you comfortable with potentially having a student shadow our therapy sessions?

[  ] Yes	[  ] No

I have read, understand and agree to abide by the above policies. 

Signature: _______________________________  Date: _________________

[  ] Adult  [  ] Parent or Guardian