MS Disease Management Program Hello, We are excited to meet you and introduce our unique Disease Management Program. As you will see, we offer a holistic approach, incorporating a broad range of programs and services to improve the quality of your life and help you regain function, reduce hospitalizations and lower health care costs. Prior to your visit, it would be very helpful if you could complete the enclosed packet of information and bring it with you to orientation. We realize it is lengthy, but the sooner we have your complete medical history, the sooner we can start you on a program to better health. Please be sure to bring with you your primary health insurance card as well as a photo ID. If you are unable to complete the paperwork, we will be glad to help you with it when you come to Total Rehab & Fitness. In the interim, if you have any questions, feel free to contact our office administration, at 856-424-5552 or at administrator@totalrehabandfitness.com. Sincerely, John Marmarou, DPT, MSCS Executive Director 1 P age
Patient Registration Form Patient s last name: First: Middle Marital Status:(Circle One) Single Marr Divorce Sep Widowed Is this your legal name? If not, what is your legal name? Social Security # Date of Birth Best phone number to reach you: Email Address: Street Address: City: State: Zip Code List current Neurologist: Neurologist s Phone # if known: List current primary care physician: Primary Care Physician s Phone # if known: Name of local relative or friend: In Case of Emergency Relationship to patient: Phone #: The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Total Rehab & Fitness. I understand that I am financially responsible for any remaining balance. I also authorize Total Rehab & Fitness to release any information required to process my claim/s. Patient/Guardian Signature: Date: 2 P age
Patient s last name: First: Today s date: DOB: Official year of your MS diagnosis and who diagnosed you: _ Please briefly explain the reason/s why you have come to TRF: _ _ _ _ Family History Is your father alive or deceased: Please state, if known, father s medical history: Is your mother alive or deceased: Please state, if known, mother s medical history: Personal History Do you currently have pain anywhere? If so please describe the location and frequency: Have you ever had any of the following? MS exacerbation Yes No Date of last exacerbation: Cancer Yes No When diagnosed: Tuberculosis Yes No When diagnosed: Diabetes Yes No When diagnosed: Heart Disease Yes No When diagnosed: High or Low Blood Pressure Yes No When diagnosed: Stroke Yes No Date of last stroke: Diabetes type II Yes No Do you test your blood sugar: Bronchitis, pneumonia, emphysema Yes No When diagnosed: Depression or anxiety disorder Yes No When diagnosed: Urinary Tract Infections Yes No When diagnosed: Hyper or hypothyroidism Yes No When diagnosed: 3 Page
Patient s last name: First: Today s date: DOB: Please list other medical conditions that you presently have: Please check off the immunomodultor you are currently taking and describe any known side effects you may be experiencing: Avonex ( interferon 1a) Rebif ( interferon 1a) Betaseron( interferon 1b) Copaxone ( glatiramer acetate) Gilenya( fingolimod) Aubagio( teriflunomide) Tecfidera ( dimethyl fumarate) Tysabri ( natalizumab) Mitoxatrone ( novantrone) Side effects you think you may be experiencing from these medications: Are you currently undergoing any monthly or quarterly steroid or chemo infusion? If so please list them: Are you currently undergoing plasmaphoresis? If so please list your weekly schedule: If possible can you please check off the phase of MS that you think you currently are in: Relapsing Remitting Secondary Progressive Primary Progressive Relapsing Progressive 4 P age
Patient s last name: First: Today s date: DOB: In the next section simply check any condition or symptom that may apply to you Arthritis or Rheumatitis Mental Health Disorder Short of breath walking 2 blocks Any bone or joint disease Frequent Headaches Short of Breath with steps Bursitis or Sciatica Anemia Blood Clots Dizziness with postion change Blurred Vision Double Vision Foot Pain Chest Pain Purple lips or fingers Swelling in legs or arms Leg Cramps with walking Joint/s Swelling Pins and needle sensation anywhere Heart Palpatations Muscle Spasms Low Back Pain Blood in Saliva Kidney Disease Pain in Arm/s Liver Disease Chronic Cough Growth in neck or throat Recent Loss of weight Fever /sweating in bed Colitis or Bowel Disease Wake up Short of Breath Inabilty to stand heat/cold 5 P age
Patient s last name: First: Today s date: DOB: Please list the month and year of your last physical examination by a primary care physician: Please list date of last MRI: Have you recently had a stress test? If so when: Have you recently had a blood testing done: Have you injured yourself from a fall recently: Are you Experiencing Difficulty with any of the following? Check all that apply: Short/long Term Memory Articulation/slurred speech Expressing your thoughts Organizing your Thoughts Keeping Attention Understanding language when spoken Eating/swollowing (coughing/choking) Difficulty with writing Self Grooming/ getting dressed Balance/mobilty effect abilty to get on/off toilet Issues manipulating buttons/zippers/laces Difficulty with lower body dressing Balance effect abilty to get in/ out of bathtube/shower Decreased sensation in hands Fatigue interfere with daily activites Feeling down, depressed or hopless Experience bouts of severe anxiety Little interest or pleasure in doing things 6 P age
ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE I acknowledge that I have received the Notice of Privacy Practice Signature of Patient or Legal Representative Date Relationship to Patient TRANSMISSION OF MEDICAL RECORDS I give Total Rehab & Fitness permission to communicate and transfer medical documents with other indicated health care professions. Signature of Patient or Legal Representative Date CONSENT FOR CARE & TREATMENT I, the undersigned, do hereby agree and give my consent for Total Rehab & Fitness to furnish care and treatment and consider this medically necessary to prevent further decline and improve my current physical, cognitive and or emotional state. Signature patient/guardian: _ Date: 7 P age
MEDICATIONS LIST PATIENT NAME: DOB: Prescription Daily Doses Prescribing Physician 8 P age
Notice of Privacy Practices This privacy notice is being provided to you as a requirement of a federal law, The Health Insurance Portability and Accountability Act (HIPAA). This notice of privacy practices describes how we may use and disclose your protected health information to carry our treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Your protected health information means any written and oral health information about you, including demographic data that can be used to identify you. We are required by Federal law to give you this Notice and to maintain the privacy of your health information. Please review it carefully. I. How We May Use and Disclose your Protected Health Information When we give you our Notice of Privacy Practices, you will be asked to sign an Acknowledgement of Receipt. Once you have received our Notice and signed the Acknowledgement, we will use your protected health information for treatment, payment and health care operations. We may use or disclose your protected health information in an emergency treatment situation. If this happens, we will try to obtain your signature on the Acknowledgement of Receipt as soon as reasonably possible after the delivery of treatment. The following examples show the types of uses and disclosures of your protected health information that our office is permitted to make. A. Treatment: Your protected health information may be used and disclosed by our office and others outside of our office that may be involved in your medical care. We will use and disclose your protected health information to other physicians to provide, coordinate, or manage your health care. For example, your protected health information may be provided to another physician or specialist to whom you have been referred to ensure that the necessary information is available to diagnose or treat you. B. Payment: Your protected health information may be used and disclosed to pay your health care bills. Your protected health information will be used to obtain payment for services we provide to you. This may include certain activities that your insurance plan may undertake before it approves or pays for the services we recommend. C. Healthcare Operations: We may use or disclose your protected health information in order to support the business activities of our practice. Healthcare operations include quality assessment activities, employee review activities, licensing or credentialing activities, conducting training and conducting auditing or review activities. For example, we may send you reminder postcards or telephone you to remind you of an appointment. We may also send you a newsletter about our practice and the services 9 P age
we offer. You may contact our Privacy Officer to request that these materials not be sent to you. D. Business Associates: We will share you protected health information with third party business associates that perform various activities for our practice. Whenever we disclose you protected health information to a business associate we will have a separate authorization to release protected health information form that will be signed by you. For example, we may disclose pertinent medical information to personal trainers or dieticians for the purpose of designing a regime that is specific to you, safe for you, and within your medical parameters. II. Use and disclosure permitted without authorization but with opportunity to object Family members and friends: Unless you object, we may disclose to your family member, a relative, a close friend or any other person you select, your protected health information to the extent necessary to help with you care of with payment for the services we have provided. We will also use our professional judgment and common practice to make reasonable decisions in your best interest in allowing a person to pick up medical supplies, x- rays, prescriptions or other similar forms of health information. III. Other disclosures that may be made without your authorization A. Required by law: We may use or disclose your protected health information when we are required to do so by law. B. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect or domestic violence or the possible victim of other crimes. We may disclose you health information to the extent necessary to avert a serious threat to your health or safety or that of other persons. C. Military personnel and national security: We may disclose the health information of Armed Forces personnel when requested by command military authorities. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence and other national security activities. D. Worker s Compensation & Health Oversight Activities: We may disclose your protected health information to comply with worker s compensation laws and to health oversight agencies when conducting investigations or inspections as authorized by law. E. Required uses and disclosures: Under the law, we must make disclosures to you and when required, to the Department of Health and Human Services when determining our compliance. 10 P age
IV. You have the following rights A. Inspect and copy your protected health information. You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practically do so. You must make the request in writing to obtain access to your health information. You may obtain access by sending a letter to our Privacy Officer listed at the end of this notice. B. Request a restriction of your protected health information. You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement, except in an emergency. C. Request an amendment of your health information: You have the right to request that we amend or correct your health information. Your request must be in writing. The request must explain why the information should be amended or corrected. We may deny your request under certain situations. D. Receive an accounting of disclosures we have made of your health information. You have the right to an accounting of disclosures of your health information that occurred after September 1, 2008. This accounting will be for purposes other than treatment, payment or healthcare operations, or disclosures we may have made to you, to your family members or friends involved in your care. The right to receive this information is subject to some exceptions. E. Make a complaint about our privacy practices. If you are concerned that we have violated your privacy rights, you may file a complaint with our Privacy Officer using the contact information listed at the bottom of this page. You may also file a written complaint with the Department of Health and Human Services. We will provide you with their address upon request. We will not retaliate against you for making a complaint or change the way we treat you. F. Request to receive confidential communications from us by alternative means or at an alternative location. You have the right to request that we communicate with you in certain ways. We will accommodate reasonable requests. We may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not require you to provide an explanation for your request. Requests must be made in writing to our privacy officer. 11 P age
V. Our duties The facility is required by law to maintain the privacy of your health information and to provide you with this Privacy Notice of ourduties and privacy practices. We are required to abide by terms of this Notice and to make the new Notice provisions effective for all future protected health information that we maintain. If the facility changes its Notice, we will provide a copy of the revised Notice by sending a copy of the revised Notice via regular mail or through in-person contact. VI. Contact Person The facility s contact person for all issues regarding patient privacy and your rights under the federal privacy standards is the Privacy Officer. Information regarding matters covered by this Notice can be requested by contacting the Privacy Officer. If you feel that your privacy rights have been violated by this facility you may submit a complaint to our Privacy Officer by sending it to: ATTN: Director of Therapy Services Total Rehab & Fitness 1111 Marlkress Rd, Suite 103 Cherry Hill, NJ 08003 12 P age