19455 Deerfield Avenue Suite 312 Lansdowne, Virginia Stone Spring Blvd, Suite 345 Dulles, VA 20166

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19455 Deerfield Avenue Suite 312 Lansdowne, Virginia 20176 24430 Stone Spring Blvd, Suite 345 Dulles, VA 20166 Patient Information: Last Name: First Name: Middle Initial: Date of Birth: / / Age:

1 19455 Deerfield Avenue Suite 312 Lansdowne, Virginia Stone Spring Blvd, Suite 345 Dulles, VA Patient Information: Last Name: First Name: Middle Initial: Date of Birth: / / Age: Social Security #: - - Sex: Male Female Marital Status: Single Married Divorced Widowed Home #: Cell #: Work #: Home Address: City: State: Zip Code: Address: Occupation: Name of Employer: Work Address: City: State: Zip Code: Referring Physician: Phone Number: Primary Physician: Phone Number: Emergency Contact: Phone Number: Insurance Information: Primary Insurance: Phone Number: Policy ID #: Group #: Primary Insured: Date of Birth: / / Social Security #: - - Effective Date: / / Name of Employer: Secondary Insurance: Phone Number: Policy ID #: Group #: Primary Insured: Date of Birth: / / Social Security #: - - Effective Date: / / 1

2 Name of Employer: How did you hear about NSMI? Please list all sports and physical activities that you participate in: Are you in seasonal competition now? Yes No Which Sport/s? Team/League or School? Position/s or Event/s? Hand Dominance: Left Right Ambidextrous History of Present Problem: Is this a work injury: Is Workers Comp Insurance being billed? Date Symptoms Started: / / What is the present problem? Please describe how the injury occurred (be specific): Location of Pain: Please mark on figures below: 2

3 How often do you have pain? Constantly Intermittently Please describe the onset? Sudden Gradual What is the quality of pain? Aching Throbbing Sharp Shooting Burning Please rate your pain score (using a scale of 0 to 10, 0= no pain and 10 =unbearable pain) Without Activity With Activity What makes the pain better? (e.g. heat, cold, sitting, laying down, meds) What makes the pain worse? (E.g. bending, lifting, standing) Have you taken part in any conservative treatment? (e.g. physical therapy, chiropractor, meds) Have you had any injections or procedures for the current problem? Please list any health care professionals who have treated you for this specific problem in the past: Past Medical History: Arthritis Emphysema (COPD) Neck Pain Asthma Fibromyalgia Osteoporosis Back Pain HIV Gout Bleeding Disorders Heart Attack Reflux Bronchitis Heart Murmur Rheumatoid Arthritis Crohns/ Ulcerative Colitis Hepatitis Seizures CHF Hypertension Sleep Apnea Blood Clots (DVT) Kidney Disease Stomach Ulcers Depression Psoriasis Stroke Diabetes Liver Disease Tumors/Cancers Diverticulosis Lyme Disease Joint Replacement Others, please explain: Past Sports related Injuries: Prior Hospitalizations (past 2 years): Past Surgical History (all body parts): 3

4 Medications (dose and frequency): Allergies: Social History: Marital Status: Single Married Divorced Widowed Do you smoke or use smokeless tobacco? Yes No; How many daily? #of years? Do you consume alcohol? Yes No; How many daily? #of years? Have you ever abused alcohol? Yes No Do you use illicit drugs? Yes No Have you abused illicit drugs in the past? Yes No Currently are you involved in any litigation/lawsuits relating to your injury? Yes No Family History: Arthritis Emphysema (COPD) Neck Pain Asthma Fibromyalgia Osteoporosis Back Pain HIV Pancreatitis Bleeding Disorders Heart Attack Reflux Bronchitis Heart Murmur Rheumatoid Arthritis Crohns/ Ulcerative Colitis Hepatitis Seizures CHF Hypertension Sleep Apnea Blood Clots (DVT) Kidney Disease Stomach Ulcers Depression Kidney Stones Stroke Diabetes Liver Disease Tumors/Cancers Diverticulosis Lyme Disease Tuberculosis Others, please explain: 4

5 Review of Systems: Your current Height: and Weight: General: Changes in Weight Changes in Appetite Changes in Sleep Changes in Taste/Smell Fatigue Fever Other Skin: Rash Itching Head/Neck: Hearing Impairment Dizziness Balance Problems Vision Problems Nose Bleed Hoarseness Mouth Sores Difficulty Swallowing Lungs: Chronic Cough Emphysema Tuberculosis Bronchitis Cardiovascular: High Blood Pressure Chest Pain Heart Attack Shortness of Breath Murmurs Congestive Heart Failure Blood Clot (DVT) High Cholesterol Gastrointestinal: Stomach Ulcers Heartburn Rectal Bleed Hernia Pancreatitis Diarrhea Constipation Urinary Tract: Kidney Stones Kidney Infections Painful Urination Incontinence Bleeding Reproductive: Sexually Transmitted Diseases Bleeding Impotence Endocrine: Thyroid Disease Pituitary/Hormonal Disease Blood/Lymphatic: HIV/AID Lymphoma Bleeding Problems Sickle Cell Anemia Musculoskeletal: Osteoarthritis Rheumatoid Arthritis Joint Pain Muscle Disorder Nervous: Fainting Headache Seizures Memory Loss Dizziness Numbness Psychiatric History: Depression Anxiety Psychosis 5

6 Authorization for Treatment and Payment I hereby request treatment by The National Sports Medicine Institute and consent to care and treatment as ordered by my physician(s). I authorize the release of information related to my treatment to my referring physician(s). I authorize The National Sports Medicine Institute to submit this claim on my behalf for the medical services provided. I hereby authorize my health insurance company to make payment(s) directly to The National Sports Medicine Institute, for any benefits that I may receive. I understand that I am financially responsible for all charges made to my account whether or not an insurance company, attorney, or third party payer is involved with payment. I am responsible for all co-payment and co-insurance amounts, noncovered supplies and services along with yearly deductibles. Payment for services is expected at the time services are rendered. I authorize the release of any information necessary to process my insurance claims and facilitate payment of my account by a third party. Signature of Patient/Guardian Date Cancellation Policy If you are unable to keep your scheduled appointment with The National Sports Medicine Institute and, or The National Sports Medicine Physical Therapy Center we required 24 hours notice to avoid a no show/cancellation fee. This allows us the ability to see another patient in need of care. Failure to provide the appropriate cancellation notice will result in a $50.00 fee. This fee must be paid prior to scheduling another appointment. Please be advised that the $50.00 fee may not be submitted to your insurance carrier for payment, this remains the responsibility of the patient. Appointments may be cancelled or rescheduled Monday through Friday 8:30 am to 4:30 pm. During normal business hours, you may reach our office by phoning: Any member of our staff will be happy to assist you. Signature of Patient/Guardian Date HIPAA Policy: I have read and received a copy of the Health Insurance Portability and Accountability Act (HIPAA). Signature of Patient/Guardian Date 6

7 Meaningful Use Patient Information Date: Name (Last, first, middle initial): PRIMARY/REFERRAL SOURCE: Preferred Pharmacy: Name: Address: Phone: Ethnicity of Patient Hispanic Origin Non-Hispanic Origin Race of Patient American Indian/Alaskan Native Native Hawaiian/Other Pacific Islander White Unknown Decline to answer Asian Black/African American Unknown Declined to answer Preferred Language of Patient: English Other Spanish Mode of Contact: Please let us know your preferred mode of communication Home Phone Mobile (cell) Phone Signature: Date: In compliance with the American Recovery and Reinvestment Act of 2009 (AARA) to demonstrate Meaningful Use, we are required to capture demographic data including your preferred language, race and ethnicity. 7

8 The National Sports Medicine Institute- Privacy Policy Please provide the names of persons if any, to whom you would permit The National Sports Medicine Institute (NSMI) to disclose personal health information as necessary for your continued health care. Please also make note if there are specific health records that you wish to not be disclosed. Otherwise, we will disclose only what is absolutely necessary to provide you with the best care in accordance with HIPAA. Listed Below those individuals you will allow disclosure of your personal health information from NSMI during the course of your care: Name and Relation: Name Relation (Initial) I acknowledge and understand that NSMI policy is to send copies of test results and/or (Initial) I acknowledge and understand that NSMI policy is to send copies of test results and/or other medical information to physicians who either ordered the procedure/consult or are in need of this health information to ensure coordinated and effective diagnosis and treatment. i.e.; your designated primary care provider or physicians/dentist seen for consult/treatment. NSMI policy is to only disclose specific information necessary for coordination of your health care or medical treatment. Signature: Date: 8

9 Authorization to Use or Disclose Health Information for Education and Research Purposes I hereby authorize NSMI and its affiliates to disclose the de-identifiable information regarding and/or relating to my orthopedic and sport medicine conditions for the purpose of EDUCATION and RESEARCH. This information will exclude any identifiable data information: EXCLUDED IDENTIFIABLE INFORMATION Name Address Phone & fax number address SSN Health plan beneficiary numbers Account numbers Certificate/license numbers Web URLs Vehicle identifiers and serial numbers Device identifiers and serial numbers IP address numbers Biometric identifiers (ex. fingerprints) Full face photo Any other unique identifier *I understand my information may be used in reports, lectures, presentations, research, and publications without identifying me by name or in any other way. NSMI will take reasonable steps to ensure confidentiality is upheld. *I understand that I may revoke the Authorization at any time. *I further understand that treatment, payment, enrollment in any health plan or eligibility for benefits is not conditioned on signing this Authorization. * I understand that information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and may no longer be protected by applicable privacy law. I further understand that the facility, its employees, officers and agents are released from legal responsibility or liability for the use and disclose of the above information to the extent indicated and authorized. (see Privacy Rule, 45 C.F.R (c)(2)) I HAVE READ AND UNDERSTAND THIS INFORMATION. I HAVE READ A COPY OF THIS FORM AND I AM THE PATIENT OR AM AUTHORIZED TO ACT ON BEHALF OF THE PATIENT TO SIGN THIS DOCUMENT VERIFYING AUTHORIZATION FOR THE USE OR DISCLOSURE OF THE PROTECTED HEALTH INFORMATION UNDER THE ABOVE STATED TERMS. Patient s Signature Date Printed Name of Patient Signature of Patient s Legal Representative (if necessary) Date 9

10 I, am aware that National Sports Medicine Institute is not in-network with the affordable Care Act plans at this time. My insurance plan is an Affordable Care Act Plan My insurance plan is not an Affordable Care Act Plan I am not sure if my health care plan is an Affordable Care Act Plan Failure to disclose this information may result in a canceled appointment of financial responsibility of the service provided. Please see the front desk with any questions about the Affordable Care Act Plans. Patient/Guardian Signature Date 10

Tracy Blum Physical Therapy, Inc NEW PATIENT REGISTRATION FORM PATIENT INFORMATION. Last Name: First Name: Middle Initial: Social Security no.

Tracy Blum Physical Therapy, Inc NEW PATIENT REGISTRATION FORM PATIENT INFORMATION Last Name: First Name: Middle Initial: Date of Birth: / / Age: Sex: M F Social Security #: / / Marital Status (circle