Insurance card Picture ID MRI/X-ray reports Therapy referral from referring physician Insurance referral if required from your insurance carrier

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1 Welcome to the Rehabilitation Center of Southern Maryland. Thank you for giving us the opportunity to care for your Physical/Occupational therapy needs. We look forward to helping you in every way we can. In order to expedite your initial visit, attached is your admission paperwork for your Physical/Occupational Therapy appointment. Please complete all of the attached forms below and bring with you to your first visit: Patient Registration History of Current Injury/Illness Form Medical/Social History form Authorization/Consent to treat Office Policies In addition, please bring the following documents: Insurance card Picture ID MRI/X-ray reports Therapy referral from referring physician Insurance referral if required from your insurance carrier We request you arrive twenty (20) minutes before your scheduled appointment for your first appointment so you can complete your remaining forms. Please allow one (1) hour for evaluations and treatment. Co-payments are expected at the time of service. We accept cash, checks, and most major credit cards. We require a twenty-four (24) hour cancellation notification if you are unable to keep your appointment time. 10 St. Patrick s Drive, Suite 401 Waldorf, Maryland (301) Malcolm Road, Suite 201 Clinton, Maryland (301) Washington St. Leonardtown, Maryland (301) Thank you for choosing the Rehabilitation Center of Southern Maryland and we look forward to meeting your treatment needs. Rehabilitation Center of Southern Maryland

2 REHABILITATION CENTER OF SOUTHERN MARYLAND -- PATIENT REGISTRATION (Please print clearly) TODAY S DATE: PATIENT S NAME: (LAST) (FIRST) (M.I.) BIRTH DATE: AGE: SS #: SEX: FEMALE MALE MARITAL STATUS: ADDRESS: ADDRESS: CITY: STATE: ZIPCODE: HOME #: WORK #: CELLPHONE #: PATIENT EMPLOYER: OCCUPATION: ADDRESS: CITY: STATE: ZIPCODE: WORK #: PARENT/SPOUSE NAME: (LAST) (FIRST) (M.I.) PARENT/SPOUSE EMPLOYER: OCCUPATION: ADDRESS: CITY: STATE: ZIPCODE: HOME #: WORK#: CELLPHONE #: DATE OF ILLNESS/INJURY/ACCIDENT: REFERRING DOCTOR: PHONE #: PRIMARY INSURANCE SECONDARY INSURANCE INSURANCE POLICY NAME: ADDRESS: PHONE #: ID/POLICY #: GROUP #/NAME: POLICYHOLDER/SUBSCRIBER NAME: POLICYHOLDER/SUBSCRIBER SS #: POLICYHOLDER/SUBSCRIBER DOB: RELATIONSHIP TO PATIENT: INSURANCE POLICY NAME: ADDRESS: PHONE #: ID/POLICY #: GROUP #/NAME: POLICYHOLDER/SUBSCRIBER NAME: POLICYHOLDER/SUBSCRIBER SS #: POLICYHOLDER/SUBSCRIBER DOB: RELATIONSHIP TO PATIENT: WORKMEN S COMPENSATION ATTORNEY INFORMATION DATE OF ACCIDENT/INJURY: INSURANCE CARRIER: ADDRESS: PHONE #: CLAIM #: CLAIM ADJUSTER: ATTORNEY NAME: ADDRESS: PHONE #: FAX: AUTOMOBILE ACCIDENT INFORMATION DATE OF ACCIDENT: AUTO INSURANCE NAME: DRIVER: YES NO ADDRESS: NAME OF INSURED/POLICYHOLDER: POLICY #: PHONE #: CLAIM #: INSURANCE AGENT NAME:

3 Medical/Social History Patient: Today s : Age: of Birth: Sex: Height: Weight: Are you: right-handed left-handed Medical History Diabetes : Insulin/meds/diet Liver disease/hepatitis Stomach Ulcers Stroke Anemia Mental health disorder Seizures Bowel/intestinal problems Bleeding disorders Glaucoma Kidney disease/stones Blood clots Ear/nose/throat/mouth problems Hiatal hernia Blood transfusions Asthma Skin disease Treatment of drug and/or alcohol problems Thyroid: hypo or hyper Prostate disease History of Cancer Lung problems Gynecologic disease Peripheral Neuropathy Heart problems Are you pregnant? Other High blood pressure Arthritis High cholesterol HIV/AIDS No known medical problems Pace Maker List any drug allergies: Latex Sensitive: No List All Previous Surgeries Month/Year List Current Medication: Prescription Non-prescription Social History Marital status: Married Single Divorced Widowed With whom do you live? Does your home have stairs? No Where? Current work status? Employed Homemaker Retired Unemployed Disabled Occupation? Current smoker? No How many packs per day? How many years? Former smoker? No How many packs per day? How many years? Alcohol use? Never/rarely Once/day Once/week Once/year Hobbies or interests? Regular exercise? Once/month Once/week 2-5 times/week Once/day Type of exercise? At the present time, would you say your health is excellent, very good, good, fair, or poor? Revised May 2010

4 History of Current Injury/Illness Name: of Onset: Today s : Have you ever been a patient here before? No Are you currently seeing any other health care provider for this condition? No Who? Have you been discharged from the hospital, a skilled nursing facility, or Home Health Agency in the past 30 days related to this condition? No Describe Please indicate for which body region you are seeking treatment: Neck Mid Back Low Back Shoulder Elbow Hand/wrist Hip Knee Ankle/foot Other When did your symptoms start? Can you identify a cause for your symptoms? No Describe: Have you ever had similar symptoms in the past? No If yes, when? Since the onset of your problem, have you had any of the following tests? No If yes, check all that apply: x-rays Bone Scan Myelogram CT Scan MRI EMG Other Pain Rating: Indicate your current level of pain by circling the appropriate number on the scale below: Pain free Unconscious pain In the past 48 hrs. what was your level pain at it s best? at it s worst Is your pain constant? No Does your pain spread? No Where? Do you have numbness, tingling, or weakness? No Where? What activities/positions make your pain worse? What activities/positions make your pain better? Did you suffer from any functional impairment prior to this onset? No Did you require an assistive device for ambulation? No Device used? Were you able to perform all activities of daily living independently prior to onset? No What are your goals for Physical Therapy? Is there anything else you wish the therapist to know about your condition? Shade Areas of Pain I have completed this form to the best of my ability and acknowledge that the information is correct. Patient Signature This information has been reviewed with the patient. Evaluating Therapist Signature Revised May 2010

5 ASSIGNMENT OF MEDICAL BENEFITS, PAYMENT RESPONSIBILITY AND AUTHORIZATION FOR TREATMENT PATIENT: 1. THE UNDERSIGNED, hereby authorize Rehabilitation Center of Southern Maryland and ITS AFFILIATES ( Provider ) to render to Patient, physical therapy, occupational therapy, or other related services (collectively, Therapy Services ) that Provider or Patient s treating physician determines may be necessary or advisable. Patient agrees to cooperate with all reasonable requests by Provider in connection with Provider s rendition of Therapy Services. 2. THE UNDERSIGNED, hereby certify that all information provided to Provider by the undersigned or Patient, including any information in connection with applying for a payment under Title XVIII of the Social Security Act, is true and accurate in all respects. 3. THE UNDERSIGNED, hereby authorize Provider to disclose any information, furnished to Provider or obtained by provider in connection with Patient s treatment (including information concerning a related Medicare claim), to any physician, governmental agency (including the Social Security Administration or any of its intermediaries or carriers), insurance company or health care facility requesting such information. 4. THE UNDERSIGNED, hereby assign to Provider all Medicare benefits and Medicaid benefits to which Patient may be entitled for any Therapy Services rendered by Provider. The undersigned hereby authorize and direct Provider to apply and file for all such benefits on behalf of Patient. In the event Patient is covered by both Medicare and Medicaid, Patient s Medicare deductible and any applicable Medicare co-payment will be covered by Medicaid. The undersigned acknowledge that Provider has disclosed to the undersigned that Provider is a supplemental Medicaid provider and that Provider is paid directly by Medicaid. In addition, the undersigned approves contact with the appropriate family members for medical claims management process. 5. THE UNDERSIGNED, hereby assign to Provider all private medical insurance benefits (primary and secondary, including med. Gap providers) or other benefits to which Patient may be entitled for any Therapy Services rendered by Provider. The undersigned hereby authorize and direct provider to apply and file for all such benefits on behalf of Patient. 6. THE UNDERSIGNED authorizes Rehabilitation Center of Southern Maryland to deposit checks received on Patient s account when made out to the patient or signed over by the patient when Insurance Company pays against services provided. 7. THE UNDERSIGNED, agree that the undersigned shall be jointly and severally financially responsible for any portion of Provider s invoice that is not paid, except in the event of Medicare denial or Medicaid eligible recipients. The undersigned warrant and represent to Provider that Patient is not a member of, or covered by, a health maintenance organization or similar arrangement. The undersigned shall be liable to Provider for all services rendered by Provider in the event Patient is covered by a health maintenance organization or similar arrangement. 8. THE UNDERSIGNED and patient agree to execute any documents and perform any act that Provider may reasonably request. The undersigned warrant and represent that attached hereto are originals or certified copies of any applicable powers of attorney, health care surrogate forms or court orders appointing the undersigned as the legal guardian of the Patient. 9. THE UNDERSIGNED, agree that the provisions hereof shall continue in full force and effect until Provider has received written notice of termination signed by the undersigned; provided, however, that the provision of paragraphs 2, 4, 5, and 6 shall survive any such termination. 10. THE UNDERSIGNED, acknowledge that Provider has disclosed to the undersigned that no physician owns any interest to Provider. 11. THE UNDERSIGNED, understands that they have a choice of rehabilitation service providers. Patient s Signature/Legal Representative/Insured Party Practice Representative Updated: 8/28/12

6 AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS I hereby authorize Rehabilitation Center of Southern Maryland, to obtain my Protected Health Information including, but not limited to, History and physical exam, lab reports, progress notes, X-Ray reports, substance abuse (including alcohol/drug abuse), Mental Health (including psychotherapy notes), HIV related information (including AIDS related testing). I understand that this authorization will expire 365 days from the date I have signed this form and that I may revoke this authorization at any time by notifying the providing organization in writing, and it will be effective on the date notified, except to the extent action has already been taken in reliance upon it. I also understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer be protected by Federal Privacy regulations. PRIVACY NOTICE By my signature below, I acknowledge that I have received a copy of this practice s Notice of Privacy Policies, detailing how my information may be used and disclosed as permitted under federal and state law and understand my rights as a patient regarding my personal health information. TREATMENT COMMITMENT Rehabilitation Center of Southern Maryland cares very much about each person we treat. We are committing to you, our patient, to deliver Exceptional Care, with Exceptional Results! We request of you, our patient, a commitment to help us deliver what we promise, by understanding what is required of you. You play a large role in your health by the actions you choose to take. Listed are some of your responsibilities as a patient as RCSM: 1. Attending, on time, all scheduled appointments. 2. Informing your therapist of your progress, each visit. 3. Compliance with your treatment plan developed by your therapist. 4. Asking questions when you do not understand any instructions given to you by our staff. 5. Notifying your therapist in advance of your next doctor s appointment. Together, we can accomplish that task set before us, as a team. That s the way healthcare is meant to be. PATIENT MISSED APPOINTMENT POLICY We strive to provide our patients with the utmost professionalism and excellence of service. Our commitment to your well-being and gain of your abilities is something everyone in our clinic takes quite seriously. Your adherence to the recommended number of treatments is a vital component of your progress with our services; therefore we have certain rules that need to be followed in order to ensure the most optimum results. In an instance of cancellation, without 24 hours notice, we reserve the right to charge you a $ In an instance of a no-show you will be charged a $25.00 fee. After the second no-show all future appointments will be removed from the schedule and you will need to call the office to reschedule appointments if you wish to resume care. In instances of repeated non-compliance with your scheduled visits, we also reserve the right to discontinue care and will inform your physician of the fact that your service has been discontinued due to non-compliance with the prescribed rehabilitation order. We appreciate you greatly as our patient and strive to accomplish wonderful results and success for you. I have read and understand all items outlined above. Signature of Insured/Patient Practice Representative Updated 8/28/12

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