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:
History of Current Injury/Illness Form
Medical/Social History form
Authorization/Consent to treat
In addition, please bring the following documents:
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
Co-payments are expected at the time of service. We accept cash, checks, and most major credit
We require a twenty-four (24) hour cancellation notification if you are unable to keep your
10 St. Patrick’s Drive, Suite 401
Waldorf, Maryland 20603
7905 Malcolm Road, Suite 201
Clinton, Maryland 20735
22715 Washington St.
Leonardtown, Maryland 20650
Thank you for choosing the Rehabilitation Center of Southern Maryland and we look forward to
meeting your treatment needs.
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: _________________ EMAIL 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: ________________________________ INSURANCE POLICY NAME: __________________________ ADDRESS: ______________________________________________ ADDRESS: ________________________________________ _______________________________________________________ _________________________________________________ PHONE #: ______________________________________________ PHONE #: ________________________________________ ID/POLICY #: __________________________________________ ID/POLICY #: ____________________________________ GROUP #/NAME: _________________________________________ GROUP #/NAME: ___________________________________ POLICYHOLDER/SUBSCRIBER NAME: _________________________ POLICYHOLDER/SUBSCRIBER NAME: ___________________ POLICYHOLDER/SUBSCRIBER SS #: _________________________ POLICYHOLDER/SUBSCRIBER SS #:____________________ POLICYHOLDER/SUBSCRIBER DOB: __________________________ POLICYHOLDER/SUBSCRIBER DOB: ____________________ RELATIONSHIP TO PATIENT: ______________________________ RELATIONSHIP TO PATIENT: ________________________
WORKMEN’S COMPENSATION ATTORNEY INFORMATION
DATE OF ACCIDENT/INJURY:_______________________________ ATTORNEY NAME: __________________________________ INSURANCE CARRIER: ____________________________________ ADDRESS: ________________________________________ ADDRESS: ______________________________________________ _________________________________________________ _______________________________________________________ PHONE #: ________________________________________ PHONE #: ______________________________________________ FAX: ____________________________________________ CLAIM #: ______________________________________________
CLAIM ADJUSTER: _______________________________________
AUTOMOBILE ACCIDENT INFORMATION
Rehabilitation Center of Southern Maryland Medical/Social History
Patient: Today’s Date:
Age: Date 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
List any drug allergies: Latex Sensitive: Yes No
List All Previous Surgeries Month/Year
List Current Medication: Prescription Non-prescription
Marital status: ___Married ___Single ___Divorced ___Widowed With whom do you live? Does your home have stairs? No Yes Where? Current work status? ___Employed ___Homemaker ___Retired ___Unemployed ___Disabled Occupation?
Current smoker? ___Yes ___No How many packs per day? _________ How many years? _______ Former smoker? ___Yes ___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?
Rehabilitation Center of Southern Maryland History of Current Injury/Illness
Name: Date of Onset: Today’s Date:
Have you ever been a patient here before? No Yes
Are you currently seeing any other health care provider for this condition? No____ Yes____ 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____ Yes____ 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____ Yes____ Describe: _________________________ __________________________________________________________________________________________________________________ Have you ever had similar symptoms in the past? Yes____ No____ If yes, when?
Since the onset of your problem, have you had any of the following tests? No____ Yes ____ 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:
0 1 2 3 4 5 6 7 8 9 10
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 Yes
Does your pain spread? No Yes Where?
Do you have numbness, tingling, or weakness? Yes____ No____
Shade Areas of Pain
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 Yes
Did you require an assistive device for ambulation? No Yes Device used? Were you able to perform all activities of daily living independently prior to onset? No Yes
What are your goals for Physical Therapy? Is there anything else you wish the therapist to know about your condition?
I have completed this form to the best of my ability and acknowledge that the information is correct.
Patient Signature Date
This information has been reviewed with the patient.
Evaluating Therapist Signature Date
Rehabilitation Center of Southern Maryland
ASSIGNMENT OF MEDICAL BENEFITS, PAYMENT RESPONSIBILITY AND
AUTHORIZATION FOR TREATMENT
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 Date
Practice Representative Date
Rehabilitation Center of Southern Maryland
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.
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.
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 $25.00. 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 Date
Practice Representative Date