Ultimate Therapy Merchants Lane, Suite 202 Leonardtown, MD ( ) ( ) Home Phone Cellular Address ( ) Occupation Employer Name Phone #

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1 Ultimate Therapy Merchants Lane, Suite 202 Leonardtown, MD Patient Information Last Name First Name Age Sex M F Street Address City State Zip ( ) ( ) Home Phone Cellular Address ( ) Occupation Employer Name Phone # ( ) Emergency Contact Person Phone # (if minor) Parent/Guardian Name and Signature Social Security # Date of Birth / / Marital Status: S M D W Work Status: currently employed retired disabled ( total or temporary) student PT FT How did you hear about us? Medical Information Referring Physician Phone Fax Referring Physician Street Address City State Zip Code Injury Illness Accident Date of onset Payment Information I am paying by: self pay Bill my insurance directly My copay/coinsurance is $. My deductible is $. Primary Insurance Subscriber Name: Date of Birth: Subscriber Address: Insurance Name: Policy# Group# Relationship to Patient: self spouse parent Secondary Insurance Subscriber Name: Date of Birth: Subscriber Address: Insurance Name: Policy# Group# Relationship to Patient: self spouse parent Office Use Only NPI Diagnosis Codes:. ;. ;. ;.

2 Assignment of Benefits to Ultimate Therapy Patient Name: I hereby instruct and direct insurance company to pay by check made out and mailed to: Ultimate Therapy P.O. Box 2327 Leonardtown, Md (301) If my/this current policy prohibits direct payment to doctor, I hereby also instruct and direct you to make out the check to me and mail it to the above address for the professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. This is a direct assignment of my rights and benefits under this policy. This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment. A photocopy of this Assignment shall be considered as effective and valid as the original. I authorize the release of any medical or other information pertinent to my case to any insurance company, adjuster, or attorney involved in this case for the purpose of processing claims and securing payment of benefits. I authorize the use of this signature on all insurance submissions. I authorize Ultimate Therapy to deposit checks made in my name. I authorize Ultimate Therapy to initiate a complaint to the Insurance Commissioner for any reason on my behalf. I understand that I am financially responsible for all charges whether or not paid by insurance. Dated this day of, 20. Signature of Policyholder Witness Signature of Claimant, if other than Policyholder

3 Ultimate Therapy Merchants Lane, Suite 202 Leonardtown, MD Ph: Fax: Statement of Privacy Notice Effective October 1, 2007 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT OUR OFFICE AT THE ADDRESS OR PHONE NUMBER AT THE TOP OF THIS NOTICE. Who will follow this notice? The information privacy practices in this notice will be followed by: Any healthcare professional that treats you at any of our locations. While each of these facilities and affiliates operates independently, they may share your health information for coordination of care treatment, payment and healthcare operations purposes. Our pledge to you: We understand that medical information about you is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive to provide quality care and to comply with legal requirements. This notice applies to all of the records of your care generated by any of the separate facilities and providers described above. We are required by law to: Keep medical information about you private; Give you this notice of our legal duties and privacy practices with respect to medical information about you; and Follow the terms of the notice that is currently in effect. How we may use disclose medical information about you: We may use and disclose medical information about you without your prior authorization for treatment (such as sending medical information about you to a specialist as part of a referral) (this includes psychiatric or HIV information if needed for the purposes of your diagnosis and treatment); to obtain payment for treatment (such as sending billing information to your insurance company or Medicare); and to support our healthcare operations (such as comparing patient data to improve treatment methods or for professional education purposes) (Note: only limited psychiatric or HIV information may be disclosed for billing purposes without your authorization). If you are treated in a specialized substance abuse program, your special authorization will be needed for most disclosures other than emergencies). Other examples of such uses and disclosures include contacting you for appointment reminders and telling you about recommending possible treatment options, alternatives, health related benefits or services that may be of interest to you. We may also contact you to support our fundraising efforts. We may use or disclose medical information about you without your prior authorization for several other reasons. Subject to certain requirements, we may give our medical information about you, without prior authorization for public health purposes, abuses or neglect reporting, health oversight audits or inspections, medical examiners, funeral arrangements and organ donation, workers compensation purposes, emergencies, national security and other specialized government functions, and for members of the Armed Forces as required by Military Command authorities. We also disclose medical information when required by law, such as in response to a request from law enforcement in specific circumstances, or in response to valid judicial or administrative orders or other legal process. Under certain circumstances, we may use and disclose health information about you for research purposes, subject to a special approval process. We may also allow potential researchers to review information that may help them prepare for research, so long as the health information they review does not leave our facility, and so long as they agree to specific privacy protections. We may disclose medical information about you to a friend or family member whom you designate or in appropriate circumstances, unless you request a restriction. We may also disclose information to disaster relief authorities so that your family can be notified of your location and condition. Other uses of Medical Information: In any other situation not covered by this notice, we will ask for your written authorization before using or disclosing medical information about you. If you choose to authorized use or disclosure, you can later revoke that authorization by notifying us in writing of your decision. Right to Access and or Amend Your Records: In most cases, you have the right to look at or get a copy of medical information that we use to make decisions about your care, when you submit a written request. If you request copies, we may charge a fee for the cost of copying, mailing, or other related supplies. If we deny your request to review or obtain a copy, you may submit a written request for a review of that decision. If you believe that information in your record is incorrect or that important information is missing, you have the right to request that we correct the records, by submitting a request in writing that provides your reason for requesting the amendment. We could deny your request to amend a record if the information is not maintained by us; or if we determine that your record is accurate. You may submit a written statement of disagreement with a decision by us not to amend a record. Right to an Accounting: You have the right to request a list accounting for any disclosures of your health information we have made, except for uses and disclosures for treatment, payment, and healthcare operations, circumstances in which you have specifically authorized such disclosure, and certain other exceptions. To request this list of disclosures, indicate the relevant period, which must be after April 14, 2003, but in no event for more than at least six years. You must submit your request in writing to our office listed at the top of this page. Right to Request Restrictions: You may request, in writing, that we not use or disclose medical information about you for treatment, payment or healthcare operations or to persons involved in your care except when specifically authorized by you, when required by law, or in an emergency. We will consider your request and work to accommodate it when possible, but we are not legally required to accept it. We will inform you of our decision on your request. All written requests or appeals should be submitted to the office listed at the top of this page. Requests for Confidential Communication: You have the right to request that medical information about you be communicated to you in a confidential manner, such as sending mail to an address other than your home, by notifying us in writing of the specific way or location for us to communicate with you. Right to request a paper copy of this Notice: You may receive a paper copy of this Notice from us upon request, even if you have agreed to receive this notice electronically. Changes to this Notice: We may change out policies at any time. Changes will apply to medical information we already hold, as well as new information after the change occurs. Before we make a significant change in our policies, we will change our notice and post the new notice in waiting areas, exam rooms, and on our website at You can receive a copy of the current notice at any time. The effective date is listed at the end. Copies of the current notice will be available each time you come to our facility for treatment. You will be asked to acknowledge in writing your receipt of this notice. Complaints: If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you may contact our office listed at the top of this page. If you are not satisfied with our response, you may send a written complaint to the U.S. Department of Health and Human Services Office of Civil Rights: DHHS, Office of Civil Rights 200 Independence Avenue, S.W. Room 509F HHH Building Washington, DC Under no circumstances will you be penalized or retaliated against for filing a complaint. By way of my signature, I provide Ultimate Therapy with my authorization and consent to use and disclosed my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice Patient s Name (print) Patient s Signature Date Authorized Facility Signature Date

4 Important Company Policies We strive to provide you the best personalized care available. To make this possible we adhere to a set of very important polices. Please read them carefully, and indicate your agreement by signing at the bottom of the page. Late Policy We greatly appreciate you allowing us to provide you with the best physical therapy possible. We want to continue to be able to do this. Our therapists and staff know your time is important and we hope you understand the value of our time. We want to be able to provide every patient with the one on one attention they require. Arriving late for any service may require us to shorten the length of service, change the therapist or reschedule for another day. 24 Hour Advance Notice Fee If you wish to change or cancel an appointment we require a minimum 24-hour advance notice. Anything less will result in a $15 fee charged to your account. Keep in mind this fee is not the responsibility of your insurance company, it will be an out of pocket expense. It costs money to make appointments available to you. Whether you attend or not we still accrue the expenses (for staff wages, rent, etc.). We don t charge you the actual cost of your appointment but rather a mere $15 fee. We do NOT make money with this charge; it s only to act as a deterrent from making last minute changes. Advance notice allows someone else (who needs it) time to reserve it in place of you. Please be courteous and responsible. Thank you. No Shows Please be courteous to our staff and other clients schedules. If you fail to show for an appointment 2 times without contacting Ultimate Therapy with a valid excuse, all future appointments will be removed and a $25 fee charged to your account for each no-show appointment. You may re-schedule appointments on a first come first serve basis. After 3 no-show appointments you will no longer be permitted to schedule any appointments in the future. If a situation arises and you know you will not be able to make your appointment please contact the office at any hour and leave a message, the phone has 24 hour voic and we will receive the message at the beginning of the next business day. Cellular Phones Cell phones must be shut off or silent. We realize emergencies may arise and therefore allow you to carry your cell phone during your session, however, please be courteous and set to silent mode or turn off. Children Children requiring supervision are not allowed to attend sessions with you. If your child does not require supervision and is capable of waiting for you quietly then you may bring them. If any disturbance is caused to other patients or staff members you may be asked to terminate your session early and tend to your child. Payment It is unlawful to routinely avoid paying your co-pay, deductible or coinsurance payments. Failure to comply places you in violation of the following laws: Federal False Claims Act, Federal Anti-Kickback Statute, Federal Insurance Fraud Laws, and State Insurance Fraud Laws. Failure to comply may result in civil money penalties(cmp) in accordance with the new provision section 1128A(a)(5) of the Health Insurance Portability and Accountability Act of 1996 [section 231(h) of HIPPA]. Signature Date / /

5 Initial Intake Form Name: Date of Birth: / / Referring Physician: Family Physician: Same Other Date of next follow up with your physician: / / GENERAL HEALTH STATUS Please rate your health: Excellent Good Fair Poor Other: MEDICAL HISTORY (Have you ever had or do you currently have any of the following?) Asthma Diabetes Severe or frequent headaches Shortness of breath/chest Pain Infectious Disease Vision or hearing difficulty Coronary Artery Disease Cancer Numbness or tingling Pacemaker Lymph Nodes Removed Dizziness or fainting High Blood Pressure Chemo Weight Loss/Energy Loss Heart Attack/Heart Surgery Radiation Hernia Blood Clot Arthritis Epilepsy/Seizures Stroke/TIA Osteoperosis Thyroid Hyper Hypo Allergies Sleeping difficulties Incontinence Pins or Metal Implants Latex Allergies Bowel or Bladder problems Joint Replacement Weakness Neck Injury/Pain Shoulder Injury/Pain Back Injury/Pain Multiple Sclerosis Elbow Injury/Pain Leg/Ankle/Foot Injury/Pain Parkinson s Other: CURRENT MEDICATIONS Please include all prescription, over-the-counter, herbals, vitamin/mineral/dietary [nutritional] supplements. List the name of the drug, dosage, frequency and how it is taken in the appropriate column. Name Dosage Frequency Route (Oral, SubQ, etc.)

6 Name: Date of Birth: / / Are you allergic to any medications that you know of? No Yes, please list CURRENT CONDITIONS Have you had 2 or more falls in the past year? No Yes Have you had a fall within the past year resulting in an injury? No Yes, describe Have you ever had surgery? No Yes, please describe and include dates (if you have a list please give to receptionist to make a copy) Describe the problem(s) for which you seek physical therapy: What do you hope to gain from physical therapy? SOCIAL HISTORY With whom do you live? Alone Parents Spouse/Significant other Other: Spouse/Significant other and children Group Setting Children Only Personal care attendant Employment Working full-time Homemaker Working part-time Student Currently not working due to condition Retired Unemployed Occupation Right Handed Left Handed Living Environment Does your house have? Where do you live? Stairs, no railing Private Home Stairs, with railing Condo Ramps Apartment Elevator Trailer Uneven Terrain Other: Do you use? Cane Walker Maunal Wheelchair Motorized Wheelchair Glasses Hearing Aide Other:

7 Name: Date of Birth: / / PAIN DRAWING Please be sure to fill this out extremely accurately. Mark the area on your body where you feel the described sensations(s). Use the appropriate symbols, mark areas of radiating pain, and include all affected areas. You may draw on the face as well. Dull/Achy Pain= D Numbness= N Stiffness= F Sharp Pain= P Tingling= T Throbbing= B Please circle the number that best describes your pain. Use the chart below to help gage your answers. Current Pain: Pain at Best: Pain at Worst: Does your pain awaken you at night? No Yes How long do you sleep before waking with pain? Do you have days or periods of time when you are completely pain free? Yes No When did these problems begin? Was the onset gradual? Yes No If there was an injury, describe the injury: How is your current condition progressing overall? Improving Staying the same Getting worse What makes the problem(s) better? Heat Ice Rest Medication Other: Are you able to continue your usual recreational activities? Yes No, explain:

8 Instructions: Please circle the level of difficulty you have for each activity today. Able to do without any difficulty Able to do with little difficulty Able to do with moderate difficulty Able to do with much difficulty Unable to do Not Applicable 1. Laying Flat Rolling Over Moving-lying to sitting Sitting Squatting Bending/Stooping Balancing Kneeling Walking-short distances Walking-Long distances Walking outdoors Climbing Stairs Hopping Jumping Running Pushing Pulling Reaching Grasping Lifting Carrying Thinking about all of the activities you would like to do, please mark an X at the point on the line that best describes your overall level of difficulty with these activities today. I have extreme difficulty I have no difficulty 23. From the list above, choose 3 activities you would most like to be able to do without any difficulty (for example, if you would like to be able to climb stairs, kneel and hop without any difficulty, you would choose: 1. 12, 2. 8, ). By signing below you are giving consent for treatment and acknowledging all information above is accurate and complete to your knowledge. Printed Name: Date of Birth: / / Signature: Date: / /