Patient Name: DOB: EMPI/MRN: Consent and Release Form Reviewed by: Date: MedStar Health appreciates the confidence you have shown in choosing us to provide for your rehabilitative needs. The service you have elected to participate in implies a financial responsibility on your part. This responsibility obligates you to ensure payment in full of your fees. As a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. However, you are ultimately responsible for the payment of your bill. Primary Insurance: Coverage: % Remaining Out of Pocket: $ # of Visits Remaining: Due at Time of Visit: Copay: $ Co-ins % Remaining Deductible: $ ($100/visit until met) Secondary Insurance: Comments: Note: This is an online or telephonic quote of patient benefits and is not a guarantee. For any questions regarding this quote, the patient or patient's guardian are advised to contact and verify benefit coverage with his/her carrier . □ Financial Agreement/Guarantee of Payment and Assignment of Benefits You are responsible for payment of any co-payment at the time of service and for any deductible/coinsurance as determined by your contract with your insurance carrier. Many insurance companies have additional stipulations that may affect your coverage. You are responsible for any amount not covered by your insurer. If your insurance carrier denies any part of your claim, or if you and your physician elect to continue therapy past your approved period, you will be responsible for your account balance in full. For your convenience, we accept cash, checks and most major credit cards. Payment is expected by payment due date on your Monthly Patient Statement. Payments can be made at the treatment facility, mailed to the address on your statement, or you may access our on-line bill payment option once a statement is received from the billing office, or by calling our customer service department. I have read the above policy regarding my financial responsibility to MedStar Health for providing rehabilitative services to the above named patient or me. I certify that the information provided as shown above is, to the best of my knowledge, true and accurate. I authorize my insurer to pay any benefits directly to MedStar Health. I agree to pay MedStar Health the full and entire amount of all bills incurred by me or the above named patient, if applicable, any amount due after payment has been made by my insurance carrier. If the actual charges exceed the estimate paid, I understand that I will be billed for the difference. Likewise, if the actual charges are less than the estimate paid, I will be entitled to a refund for the amount paid in excess of the actual charges. Signature: (relationship to patient: self - guardian - other: ) Date: □ Consent of Treatment & Authorization to Release Information I am aware of my diagnosis and voluntarily consent to have MedStar Health, through its appropriate personnel, provide evaluation and/or treatment as prescribed by my physician and/or recommended by my therapist. I understand that if I fail to carry out the follow-up medical care, I do so at my own risk. I understand that those individuals who attend patients at this facility may include medical, nursing, and other health care personnel in training who, unless requested otherwise, may be present during patient care or may provide care as part of their education. I also understand that the rehabilitation process, by its very nature, involves certain inherent and unavoidable risks, including falls, and other similar injuries, and that the only alternative to entirely avoid these risks would be to forego rehabilitation altogether. I understand that I have the right to ask my therapist questions at any time during the course of my care. Signature: (relationship to patient: self - guardian - other: ) Date: I further authorize MedStar Health to release to appropriate agencies, any information acquired in the course of my or the above named patient’s examination and treatment necessary to secure payment for services provided. Signature: (relationship to patient: self - guardian - other: ) Date: 2020 Patient Name: DOB: MR: Outpatient Health History (Confidential) Date: ____________ Emergency Contact: ____________________________________ Relationship: __________________ Phone #:_______________ Person Completing form: Patient Other_ ___________________________________________________________________ Reason for Referral: _____________________________________________________________________________________________ MEDICAL HISTORY (PLEASE CHECK ALL MEDICAL DIAGNOSIS AND CONDITIONS THAT APPLY) Anemia Depression Joint Replacement / Metal Implant Arthritis Diabetes Kidney Problems Asthma Dizziness Osteoporosis Bleeding Disorders Emphysema Motor Vehicle Injury Cancer Epilepsy / Seizures Pacemaker Chest Pain Gout Current Pregnancy Chemical Dependency Headaches Stroke Communicable Disease: Heart Disease Thyroid Problem COVID19+ HIV+ HPV High Blood Pressure Tuberculosis MRSA VRE E Coli Insomnia Ulcers Scabies Herpes Zoster Irregular or Rapid Heart Beat Work Injury ______________________________ Other medical condition if not listed above: ____________________________________________________________________________ PAIN: Do you currently have pain or have you had pain in the recent past? YES NO If Yes, specify _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ DO YOU CURRENTLY HAVE ANY OF THE FOLLOWING SYMPTOMS? Productive cough Yes No Trouble breathing Yes No Constipation Yes No Fever / Chill Yes No Joint pain Yes No Bloody Stools Yes No Coughing up blood Yes No Joint stiffness Yes No Difficulty or pain with urination Yes No Night sweats Yes No Rashes or skin changes Yes No Incontinent bladder Yes No Nausea / Vomiting Yes No Visual changes Yes No Incontinent bowel Yes No Chest pain Yes No Hearing changes Yes No Other:_____________________ Yes No NUTRITION: Are you concerned about your Nutrition? Yes No Have you had an unexplained weight loss? Yes No Have you had an unexplained weight gain? Yes No Specify loss or gain: ______lbs FALLS: Are you concerned about falling? Yes No Have you fallen in the last year? Yes No If yes, Date: _________ Have you fallen more than 2 times? Yes No Has any fall resulted in injury? Yes No Specify:________________ IMMUNIZATION: (For Pediatric Patients Only) Check () if you have been immunized for the following: DPT (Diphtheria, Pertussis, Tetanus) Yes No Chickenpox (Varicella) Yes No MMR (Measles, Mumps, Rubella) Yes No SURGERIES / HOSPITAL PROCEDURES __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ ALLERGIES / DRUG INTERACTIONS Many rehab clinic products contain Latex. Do you have any allergy to Latex? Yes No __________________________________________________________________________________________________________________________________________ CURRENT MEDICATIONS (INCLUDE OVER-THE-COUNTER MEDICATIONS AND HERBAL PREPARATIONS) Medication Name Dose Frequency Reason The information on this form will be reviewed and discussed with the patient, and the information will be incorporated into the treatment goals and plan of care established in collaboration with the patient. Refer to individual service area evaluations and care plans. 2020 Patient Name: DOB: EMPI/MRN: Notice of Privacy Practices Receipt / Waiver Documentation Form In compliance with federal regulations, we are required to distribute the MedStar Health “Notice of Privacy Practices” to all patients. Option 1: If you wish to receive a printed copy of the privacy practices, please sign below and a Team Member will provide one. • I request a printed copy of the MedStar Health “Notice of Privacy Practices”. Patient Name (please print) Patient Signature Date Received Option 2: If you wish to waive receipt of a printed copy of the privacy practices, please sign below. • I have been offered the MedStar Health “Notice of Privacy Practices” and waive receipt of a printed copy. Patient Name (please print) Patient Signature Date 2020 Patient Name: DOB: EMPI/MRN: ATTENDANCE POLICY Welcome to Medstar Health. Our goal is to provide you with the best physical therapy services to improve your function and reach your therapy goals (PT, OT, SLP) and/or your skills for independent living. Because we feel consistency is vital to achieve maximum benefit from your therapy, we have initiated the following procedure for appointments & attendance policy. If you will be late or are unable to attend a session, please call promptly to reschedule. • If you cancel three (3) therapy sessions within one month (a cancel with less than 24 hours notice) you will be discharged from therapy. • If you miss two (2) therapy sessions in a row and do not call to cancel, you will be discharged from therapy. • If you miss three (3) therapy sessions at any time during your course of therapy and do not call to cancel those sessions, you will be discharged from therapy. ** IF YOU NO SHOW OR CANCEL AN APPOINTMENT, WITH LESS THAN 24 HOURS NOTICE, YOU WILL BE CHARGED