RD Physical Therapy & Wellness, LLC

RD Physical Therapy & Wellness, LLC Tel: 443-253-4603 Fax: 410-720-2690 Clinic Location : 3450 Ellicott Center Dr., Suite 105 Ellicott City, MD 21043 Patient information: Registration Form Last name: First name: Middle initial: Street Address: City: State: Zip: Home Phone: Cell Phone: Email: Insurance Information: Insurance Name: Policy/ID #: Emergency contact: Name: Phone number: Relation to patient: Physician: Name: Phone number: Referral needed: Allergies: (if any) Reason For Visit: How did you hear about us: Yes No

RD Physical Therapy & Wellness, LLC Tel: 443 253 4603 Fax: 410 720 2690 Clinic Location : 3450 Ellicott Center Dr., Suite 105 Ellicott City, MD 21043 Patient Financial Policy ***Please Read Carefully*** We are pleased to have you as our patient and we are committed to providing you with our best professional care. Your clear understanding of our financial policy is important to our relationship. This form must be signed and dated before treatment can be initiated with our therapist. Our Fees: PT evaluation: $75 PT evaluation and treatment: $105.00 Routine Treatment: $90.00 We have set our fees with a goal of being responsible and fair. They have been aligned with resources based on relative value scale and geographically adjusted for physical therapy within the surrounding area. We do not accept the insurance industry s usual and customary fee scheduled and expect payment in full for services rendered. Any dispute regarding the fees charged and their definition of usual and customary is between you and your insurance carrier. *( ) Initial Here Payment Method: We accept cash, check, or credit card. If you need to make a payment arrangement due to financial hardship, our business office requires patient to call to make mutually satisfactory payment arrangement. Physician Referrals: It is your responsibility to obtain any pre authorization or referrals required by your insurance carrier. It is your responsibilities to accept liability for charges should your health carrier deny any benefits. Children: Often the person responsible for the children s bills is unclear. In our office, the person who brings the child in and requests treatment is the person who is responsible for all fees incurred. Therefore, if you brought the child today, we ask that you provide us with your home address and the phone number for billing purposes.

Insured Patients WE DO NOT PARTICIPATE NOR ARE WE A PROVIDER WITH ANY INSURANCE COMPANY. SERVICES RENDERED ARE CONSIDERED OUT OF NETWORK. You are responsible for deductibles (if not met), co pays, co insurance, not covered services, and items deemed not medically necessary by your insurance company. Since there is no way for this office to determine whether your insurance company will pay for the services performed during your first session, payment in full is required for the initial visit and at the time of each visit thereafter. Your insurance policy is an agreement between you and your insurance carrier. The patient or guarantor must resolve any discrepancy or dispute of payment. Services that are not covered by the insurance carrier and any outstanding balances are your responsibility. All statements must be initialed: Additional Policies & Information * 24 Hour Cancellation Policy: A 24 hour cancellation notice must be received to avoid charges. Continuity of your treatment is the basis for your insurance company substantiating the Medical Necessity for your care. Three (3) missed or cancelled appointments will result in your discharge from physical therapy services. $50.00 charge will be assessed for each cancelled visit. * Legal Recourse: If outstanding balance remains after 120 days, the undersigned irrevocable authorizes any attorney of any court to appear for the undersigned at any time after default in the payment of any outstanding balance and confess judgment without process if favor of the provider of service. All costs of collections, including attorney fees, are the responsibility of the patient. In addition, I agree to pay RD Physical Therapy & Wellness, LLC an inconvenience fee of $125.00 per hour for any and all time spent by an employee of RD Physical Therapy & Wellness, LLC in the collection of any outstanding bill owed for services rendered. I have read and agree to the Financial Policy, Payment Agreement, Legal Recourse, and Release of information as it applies to me. Patient Name (Print) Patients Signature Date Would you like a copy of this financial policy? Yes No Please Call our business office if you have any questions or problems with your account.

RD Physical Therapy & Wellness, LLC Tel: 443-253-4603 Fax: 410-720-2690 Clinic Location : 3450 Ellicott Center Dr., Suite 105 Ellicott City, MD 21043 PATIENT CONSENT FORM Name: DOB: Through the use of this consent form, I authorize RD Physical Therapy & Wellness, LLC to perform the followings: (Item 1 and 2 must be checked before treatment begins with the therapist) 1. Request evaluation and treatment from RD Physical Therapy & Wellness, LLC 2. To exchange/release personal information with those care professionals treating/practicing on site, who are directly involved in the care of myself or my dependant(s) so they may understand my/his/her medical condition and needs. 3. To release to (if the health care professional is not located on-site): 4. To release information pertaining to an auto or personal injury accident to attorney s office, insurance agencies. 5. To receive form (if the health care professional is not located on site): (Name of person, Doctors name, Organization, attorney s office, or institution-for items 3, 4 and 5.) (Address) Phone# Fax# The following Information: Patient History Information Behavioral Report Medical Records Teacher s Report Education/ Academic Records Verbal Exchange Psychological Evaluation Other information Neurological Evaluation X-Ray s/mri s (State Other Reason) I have read and understand the foregoing notice and all of my questions have been answered to my complete satisfaction in a way I can understand. I have reviewed the notice of Privacy Practice. Patient s Name (Please Print) Date Signed / / Signature of Individual ****RELEASE IS VALID FOR DURATION OF THE TREATMENT****

RD Physical Therapy & Wellness, LLC Tel: 443-253-4603 Fax: 410-720-2690 Clinic Location : 3450 Ellicott Center Dr., Suite 105 Ellicott City, MD 21043 MEDICAL HISTORY FORM: Patient Name DATE: Present Symptoms / what is your majorcomplaint? When did you first notice major complaint/what brought it on? What activities aggravate condition? Is this condition interfering with your work? No Yes Constant Comes and goes Is this condition interfering with your daily routine? No Yes What have you done to get relief? Has there been a medical diagnosis? No Yes Any X-Ray? Scan? MRI? Blood work? Describe: Have you ever had this problem before? No Yes - If yes, when? What caused those episodes? What relieved them? Did they disable you? No Yes Did they prevent you from working? No Yes. Hospitalization: Are you on any medications? No Yes If yes, list them: Have you ever: Had any operations? No Yes/Describe Broken any bones? No Yes/Describe Been in an accident? No Yes/Describe Did you receive a whiplash? No Yes (Please circle all that apply) I primarily sleep on my: Side Back Stomach (Please circle all that apply) Do you wear: Heel lifts? Orthotics? Arch supports? Inner soles? Are you pregnant? DO you have a pacemaker?

Please inform us if you have had a special procedure done? (mesh for hernia, breast implant, etc.) RD PHYSICAL THERAPY & WELLNESS, LLC PH: 443-253-4603 FAX: 410-720-2690 Medical/surgical history: Please Mark One Box For Each Item Metal implants / pacemaker Diabetes Yes Please Mark One No Box For Each Item Unexplained weight loss Unexplained weight gain Heart condition Night sweats High blood pressure Fever (recent- <3 mths) Chest pain Arthritis Bladder/bowel problems Osteoporosis Kidney condition Anxiety Blood clot / DVT Seizures Cancer Sinus infections Breathing difficulties / asthma Jaw pain/clicking Dizziness/vertigo Allergy to latex (gloves) Ringing in ears Other allergy Double vision Fractures No Yes

RD PHYSICAL THERAPY & WELLNESS, LLC PH: 443-253-4603 FAX: 410-720-2690 Pain Chart: Mark with (x) or shade the areas of pain. Pain Scale: (0-no pain, 1 to 3-mild pain, 4 to 7 moderate pain, 8 to 10 severe pain) Present: At best: At worst:

Frequency: (circle one) constant / intermittent / variable

HIPAA NOTICE OF PRIVACY PRACTICES 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. This notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by your physician, our office staff and other outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law. Healthcare Operations : We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required by Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers' Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500. Treatment : We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to or referred by to ensure that the physician has the necessary information to diagnose or treat you.

Payment : Your protected health information will be used, as needed, to obtain payment for your health care services. Other Permitted and Required Uses and Disclosures Will be made only with your consent, authorization, or opportunity to object unless required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician's practice has taken an action in reliance on the use or disclosure indicated in this authorization. Your Rights: statement of your rights with respect to your protected health information You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you agreed to accept this notice alternatively i.e. electronically. You may have the right to have your physician amend your protected health information. If we deny request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.