Outpatient Rehabilitation Orders

Patient Name: ______Date of Birth: ______/ ______/______Day/Work Phone: ______Cell Phone: ______Diagnosis:______Goals/Comments/Special Instructions: ______Follow-up Visit (with referring physician) ______/______/______□ Physical Therapy Frequency ______Duration ______(wks/visits) □ Physiatry/Physician Services □ Occupational and/or Hand Therapy Frequency ______Duration ______(wks/visits) Frequency ______Duration ______(wks/visits) □ Psychology Services □ Speech/Language Pathology Frequency ______Duration ______(wks/visits) Frequency ______Duration ______(wks/visits) I certify the necessity of this treatment ➧ Physician Signature ______Date:______NPI #______Physician Name (print clearly) ______Tax ID #______Office Phone: ______Fax:______Email (if preferred contact method):______

PHYSICAL THERAPY OCCUPATIONAL THERAPY PM&R SERVICES c EVALUATE & TREAT c EVALUATE & TREAT c Bethesda c Friendship Heights c c c Aquatic Therapy c ADL/Self-Care Irving Street Montgomery c c Back Education & Back School c Assistive/Adaptive Equipment Georgetown General c Biofeedback c Cognitive Skills Training University Hospital c c c Electrical Stimulation/TENS c Electrical Stimulation Treatment Consultation c c c EMG/Nerve Conduction Energy Conservation Energy Conservation/Joint Protection c c Facial Palsy c Functional Mobility Fluoroscopic Injection (Bethesda, Irving Street and Georgetown locations) c Falls Prevention c Hand Therapy (see separate category) c Geriatric Rehabilitation c Flexibility c Vision: Evaluate & Treat c Independent Medical Evaluation (IME) c Functional Mobility c Manual Therapy c c c Joint/Trigger Point Injection Gait Training Neuro Re-education c Osteopathic Manipulation (Bethesda, c c Home Exercise Program Perceptual Motor Skills Training Irving St) c c c c Manual Therapy Strengthening ROM Dexterity c Oncology Rehabilitation c c Posture Training Splinting/Orthotic Fabrication/Training c Neurological Disorders c Orthotics/Prosthetics c Work/Community Skills c Second Opinion c Orthotic Fabrication c Other: ______c Workers’ Comp Evaluation & Treatment c Stabilization: Lumbar/Cervico-Thoracic c Strengthening c ROM HAND THERAPY (PT/OT) OCCUPATIONAL REHABILITATION (PT/OT) c Traction: Cervical/Lumbar c Back Education & Training c EVALUATE & TREAT c Ultrasound/Phonophoresis c Functional Capacity Evaluation (FCE) c c Vestibular/Balance Training Splinting c Work Conditioning c Whirlpool c dynamic c static c Worksite Evaluation/Ergonomic Analysis c Other: ______c forearm c hand c finger c Other:______c flexion c extension ADDITIONAL PROGRAMS WOMEN’S HEALTH c ROM (Range of Motion) c AROM c AAROM c PROM c Acupuncture** c EVALUATE & TREAT c Strengthening c Amputee Program/Vascular/Pain* c Breast Cancer Rehabilitation c Other: ______(MD, PT, Psy) c Continence Program c Baclofen Pump Maintenance/Refills* c Lymphedema Management c PSYCHOLOGY Cerebral Palsy Interdisciplinary Clinic* c Upper c Lower c Chronic Pain Management** (MD, PT, OT, c c Pelvic Pain Rehabilitation Consultation & Treatment Psy) c c Other: ______Adjustment to Illness Counseling c Continence/Pelvic Pain** (men & women) c Healthy Lifestyle Counseling c Driving Evaluation (PT/OT/RE)* c c SPEECH/LANGUAGE PATHOLOGY Independent Medical Evaluation (IME) Fibromyalgia Management c Medical Illness Counseling c Foot & Running Clinic c EVALUATE & TREAT c Neuropsychology Assessment c Modified Barium Swallow* c Language/Communication c Pain Management c Neurological Day Treatment Program* c Cognitive — Communication Treatment c Relaxation Training/Stress Management (Stroke, TBI) c c Dysphagia/Swallowing c Sleep Hygiene Post-Polio Clinic* (PT, OT, SW, MD) c c Voice c Smoking Cessation Rehab Engineering Assistive Technology* c c Voice Training Services c SCI Fertility Clinic* Other: ______c c Augmentative/Alternative Communication Seating/Mobility/Wheelchair Clinic (PT/OT/RE) c Articulation (Pediatrics) c Spasticity Clinic (Botox Injections)* (MD,PT) c Accent Modification c Spinal Cord Injury Day Treatment Program* c Patient/Family Education & Training c Vocational Rehabilitation* c Aphasia Clinic c c Wound Clinic* Other: ______c Other:______* Irving Street /Main Hospital outpatient location only. **Services only offered at limited locations; please www.nrhrehab.org call location nearest you for assistance to find where offered. Washington, DC NRH Rehabilitation Network MedStar NRH Rehabilitation Network Germantown* Perry Hall Outpatient Physicians Center Suburban Wellness Center 5009 Honeygo Center Drive, 102 Irving Street, NW 20500 Seneca Meadows Parkway, Suite 209 Washington, DC 20010-2949 Suite 101 Perry Hall, MD 21128 202-877-1621 202-829-2632 FAX Germantown, MD 20876 443-725-2150 443-725-2155 FAX MedStar NRH Rehabilitation Network 301-916-8500 301-528-6258 FAX MedStar NRH Rehabilitation Network Irving Street NRH Rehabilitation Network Wilkens Avenue 102 Irving Street, NW Montrose* 3455 Wilkens Avenue, Washington, DC 20010-2949 6001 Montrose Road, Suite 306 Physical and Occupational Therapy Suite 402 , MD 21229 202-877-1760 202-829-2789 FAX Rockville, MD 20852 410-737-8418 410-536-7127 FAX 301-984-6594 301-984-7271 FAX Speech/SLP, Dietary, Psychology, Vocational MedStar NRH Rehabilitation Network Rehab, Rehab Engineering NRH Rehabilitation Network Lutherville Hand Center 202-877-1440 202-291-2836 FAX Olney*** 1400 Front Avenue, Outpatient Center for Orthopaedic Rehab 18109 Prince Phillip Drive, Suite 205 (OCOR) Suite 155 Lutherville, MD 21093-5363 A part of MedStar NRH Rehabilitation Olney, MD 20832-1591 410-823-4263 410-823-1861 FAX 301-570-3138 301-570-3139 FAX Network MedStar NRH Rehabilitation Network 102 Irving Street, NW NRH Rehabilitation Network Lutherville Sports Medicine Washington, DC 20010-2949 Wheaton* 1407 York Road, 202-877-1566 202-877-1113 FAX Westfield North Suite 100 NRH Rehabilitation Network 2730 University Boulevard West, Lutherville, MD 21093-6077 K Street, NW* Suite 812 410-512-5820 410-512-5859 FAX Wheaton, MD 20902-1977 2021 K Street, NW, MedStar NRH Rehabilitation Network 301-962-7612 301-962-7782 FAX Suite 215 Stadium Place Washington, DC 20006-1003 900 East 33rd Street 202-466-9719 202-466-9465 FAX Prince George’s County Baltimore, MD 21218 410-366-0791 410-366-0930 FAX NRH Rehabilitation Network MedStar NRH Rehabilitation Network 19th Street, NW* Mitchellville Howard County 1145 19th Street, NW, 12140 Central Avenue Suite 403 Mitchellville, MD 20721-1932 MedStar NRH Rehabilitation Network Washington, DC 20036-3701 301-390-3076 301-390-3725 FAX Ellicott City 202-721-7680 202-955-7998 FAX Dorsey Hall Medical Center MedStar NRH Rehabilitation Network 9501 Old Annapolis Road, Oxon Hill Virginia Suite 125 6196 Oxon Hill Road, Ellicott City, Maryland 21042 MedStar NRH Rehabilitation Network Suite 450 410-997-1063 410-997-1408 FAX Ballston Oxon Hill, MD 20745-3108 3833 North Fairfax Drive, 301-839-0400 301-839-0130 FAX Southern Maryland Suite 300 Arlington, VA 22203 Baltimore Area NRH Rehabilitation Network 703-717-6900 703-717-6909 FAX St. Mary’s** MedStar NRH Rehabilitation Network 24035 Three Notch Road (Site location) Bel Air MedStar NRH Rehabilitation Network P.O. Box 940 (Mailing address) McLean (Opening Fall 2012) 658 Boulton Street, Hollywood, MD 20636 6858 Old Dominion Drive Suite A 301-373-2588 301-373-4558 FAX McLean, VA 22101 Bel Air, MD 21014-4214 410-638-9400 410-638-9061 FAX NRH Rehabilitation Network Montgomery County Waldorf** MedStar NRH Rehabilitation Network 3 Post Office Road, Dundalk NRH Rehabilitation Network Suite 105 Bethesda* 1576 Merritt Boulevard, Waldorf, MD 20602 6410 Rockledge Drive, Suite 7 301-893-2345 301-638-1783 FAX Suite 600 Baltimore, MD 21222-2114 Bethesda, MD 20817-1844 410-650-2145 410-282-5955 FAX Anne Arundel County 301-581-8030 301-581-8031 FAX MedStar NRH Rehabilitation Network MedStar NRH Rehabilitation Network MedStar NRH Rehabilitation Network MedStar Good Samaritan Hospital Pasadena Chevy Chase Walker Building, First Floor 8109 Ritchie Highway, Entrance B 5454 Wisconsin Ave., 5601 Loch Raven Boulevard Pasadena, MD 21122-6917 Street Level Baltimore, MD 21239-2905 410-590-8750 410-590-8755 FAX Chevy Chase, MD 20815 443-444-5757 443-444-5750 FAX 301-951-0546 301-215-4488 FAX Eastern Shore MedStar NRH Rehabilitation Network NRH Rehabilitation Network Harborview Sports Medicine Peninsula/NRH Rehabilitation Network Friendship Heights* (Across from MedStar Harbor Hospital campus) Salisbury† 5530 Wisconsin Avenue, 2900 South Hanover Street, 1655 Woodbrooke Drive, Suite 960 Suite 102 Suite 102 Chevy Chase, MD 20815-4404 Baltimore, Maryland 21225 Salisbury, MD 21804 301-986-4745 301-657-4678 FAX 410-350-8372 410-350-3821 FAX 410-546-2702 410-546-8272 FAX www.nrhrehab.org

The NRH Rehabilitation Network is a growing network of outpatient therapy centers located throughout Maryland, the District of Columbia and Northern Virginia. It is a part of MedStar National Rehabilitation Hospital (MedStar NRH). A number of centers are a joint service of MedStar NRH and (*); MedStar NRH, Calvert Memorial Hospital, Calvert Physical Therapy and Sports Fitness Center, Civista Hospital and MedStar St. Mary’s Hospital (**); MedStar NRH, MedStar Montgomery Medical Center and Suburban Hospital (***); and MedStar NRH and Peninsula Regional Health System (†) 0812