Instructions:  Please sign and complete all the below information. When completed, please fax or mail back to arrive at least 24 hours before your session.  Fax: 240-392-4594   Mail: 4541 Timbery Drive, Jefferson, Maryland 21755-7701

Today’s Date: _  _  / _  _  / _  _  

Primary Care Physician:  Name: _____________________________  Phone: ( _  _  _  ) _  _  _ – _  _  _  _

Patient Personal And Contact Information

Name: First, Middle Initial, Last:  __________________________________________________________

Date of birth: _  _ / _  _ / _  _  _  _            Age: _________      Gender:  ___Male  ___Female             

Street address: _______________________________________________________________________

City, State, Zip: _______________________________________________________________________

Phone:  ( _  _  _ ) –  _  _  _  –  _  _  _  _                               Cell Phone:  ( _  _  _ ) –  _  _  _  –  _  _  _  _

Email: ________________________________

Social security number: _  _  _  –  _  _  –  _  _  _  _

Marital status:   ___ Single    ___Married   ___Divorced   ___Windowed   ___N/A

Emergency Contact Information:

Name:First, Last _______________________________   Relationship: ___________________________

Phone:  ( _  _  _ ) – _  _  _  –  _  _  _  _          Email: ______________________________________________

Approved Caregivers or Facilitators Approved to be Present During Session, if Any:

Name:First, Last _______________________________   Relationship: ___________________________

Phone:  ( _  _  _ ) – _  _  _  – _  _  _  _          Email: ______________________________________________

Best Form of Contact:  ___Phone   ___Email  ____Text message

Okay to leave voice message: ___Yes   ___No

Chief Complaint or Problem (what brings you here today)?  ___________________________________________________________________________________


Medications:  List any medications including over the counter, vitamins and supplements, eye drops, or medicated body lotions (if needed, use the back of the form to add more).
           Medication                                          Dosage                            Frequency Taken

1.  _________________________________________________________________________________

2.  _________________________________________________________________________________

3.   _________________________________________________________________________________

4.   ________________________________________________________________________________

5.   ________________________________________________________________________________

6.   ________________________________________________________________________________

7.   ________________________________________________________________________________

8.  ________________________________________________________________________________

9.   ________________________________________________________________________________

10.   ________________________________________________________________________________

Smoking History:  ____Yes   ___No    If yes, currently smoking: ___Yes  ____No

Occupation: ________________________    Retired: ____Yes  ___No        Student:  ____Yes  ___No

Hobbies, Interests: ___________________________________________________________________

Screening Tools:  

I have problems with swallowing or recently choked: ___Yes  ___No

I have soreness/pain when I move that affects the quality of my life: ___Yes  ___No

I have lost my balance and/or fallen with or without injury this year: ___Yes  ___No

I can’t bath or dress myself completely: ___Yes  ___No

I have moments of confusion or forgetfulness:___Yes  ___No

Would you like to receive our newsletter?  ___Yes  ____No

Who can we thank for referring you today?

___Internet search   ____Social media       ____Word of mouth  ____Other, If yes where: ___________________

Clinician (name, specialty): _______________________________________________________________




I hereby authorize Rehab Smarter to provide diagnostic and therapeutic services, either prescribed by my physician or self referral, that are considered by initial and ongoing assessment to be clinically appropriate to treat my disease, injury, or disability.                                                                                                             


I understand that during the course of my care the need for emergency treatment and/or transfer to a hospital may be necessary.  I understand that Rehab Smarter does not provide emergency medical care and therefore should the need for such treatment and/or transfer be deemed necessary and appropriate, agency staff will call 911.  I agree to assume sole responsibility for all charges incurred for such treatment.                                                                                            


Services will be provided by licensed, experienced professionals in their fields.  All procedures will be thoroughly explained to me before I am asked to perform them.  It is my right to accept or refuse any part of my treatment at any time before or during treatment.  Services are provided to individuals of all ages regardless of gender, color, ethnicity, creed, national origin, or disability.  It is my right to ask my clinician about the treatment they have planned based on my individual history, diagnosis, symptoms, and examination results.  Consequently, it is my right to discuss the potential risks and benefits involved in my treatment with my clinician.

It is my responsibility to fully cooperate, participate, and comply with the established plan of care to best obtain the desired end outcome.  I have read and understand my rights and responsibilities and any questions or concerns have been explained to me orally by a representative of Rehab Smarter and have received a copy of this.                                                                                                  


I authorize any physicians, hospitals, nursing homes, clinics and other health care providers to release medical information relevant to my care with Rehab Smarter.    I hereby authorize the release of any medical information from my records to any licensed institutions, case management, accreditation and regulatory bodies and other health providers for the purpose of providing continuity of care.  I place no limitations on history of illness or diagnostic/therapeutic, information including any treatment for substance abuse, psychiatric disorders, or acquired immune deficiency syndrome. 

Rehab Smarter Inc may also disclose on an anonymous basis any information concerning my case, which is necessary or appropriate for the advancement of medical science, medical education concerning research, for the collection of statistical data or pursuant to state or federal law, statute or regulation. A copy of this authorization may be used in place of the original.                        


I authorize Rehab Smarter to charge me directly for services provided at the time service is rendered.  I have the right to request a detailed bill to submit to my insurance company for reimbursement but understand that there is no guarantee they will be covered by my insurance company.  However, it is understood that the undersigned and/or the patient are primarily responsible for the payment of my bill.  Please consult directly with your insurance provider to determine coverage prior to the session.                                                                                                                          


I understand that Rehab Smarter follows HIPAA guidelines which provide data privacy and security provisions for safeguarding my medical information and that I have read, understand and received a copy of the statement of this agency’s Notice of Privacy Practices.


I understand and authorize audio, video and photographs of myself to be taken and kept in HIPAA compliant storage.  These audio, video and photographs will be used to allow Rehab Smarter to provide  appropriate assessment and treatment and for professional use only.  Any identifying details will be removed prior to sharing professionally outside of Rehab Smarter staff and other health care providers relevant to my care.                                           


I understand that in order for Rehab Smarter to provide services over the Internet that I will need a high speed Internet connection of of at least 15Mbps download / 5Mbps upload time.  Check here and click “Begin” to test your device), computer or tablet video camera, and voice capabilities.  I understand that should there be equipment issues or connection failures on either end that all efforts will be made to ensure a full session is delivered.  In the event the session needs to be ended, or the connection is cut off, I understand Rehab Smarter will reschedule my session to complete it at a mutually appropriate time.   

Rehab Smarter uses HIPAA compliant software and connections and in- house policies and procedures to ensure your privacy over the internet.  As in any internet environment, the slight possibility of a violation of this connection is however slight but possible.  I will not hold Rehab Smarter Inc responsible for these unanticipated infractions of privacy.   

Payment must be made in full at the time of services rendered. We do not accept any payment plans.  If you cannot attend your appointment please call with at least 24 hours in advance to cancel.  PLEASE NOTE: Cancellations without 24 hour notice may result in a $50 charge.

By signing below you have read, understood, and accepted all the information contained in this document.        

__________________________________________________________________    _  _  / _  _  / _ _ _ _ 





Our Legal Duty

We are required by applicable federal and state law to maintain the privacy of your medical information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your medical information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect 01/01/2016, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all medical information that we maintain, including medical information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request.

You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.

Who Will Follow This Notice

This notice describes our privacy practices that our clinicians and associates will follow to protect your personal protected health information.

Uses and Disclosures of Medical Information

We use and disclose medical information about you for treatment, payment, and health care operations. For example:

We may use or disclose your medical information to a physician or other health care provider in order to provide treatment to you.

Insurance Reimbursement
We may use and disclose your medical information to provide you information to submit to your insurance company for reimbursement for our services. We may disclose your medical information to another health care provider or entity subject to the federal and state Privacy Rules so they can obtain payment.

Health Care Operations
We may use and disclose your medical information in connection with our health care operations. These uses are necessary to make sure that all our patients receive quality care.   An example is: To review of our treatment or services to evaluate the performance of our staff providing your care;

On Your Authorization

You may give us written authorization to use your medical information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your medical information for any reason except those described in this notice.

Appointment Reminders

We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the office.

To Your Family and Friends

Unless you object, we may disclose your medical information to a family member, friend or other person to the extent necessary to help with your health care or with payment for your health care.

If you are not present, or in theevent of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest. We will also use our professional judgment and our experience with common practice to allow a person to pick up filled prescriptions, medical supplies, x-rays or other similar forms of medical information.

By Law or Special Circumstances
We may use or disclose your medical information as authorized by law for the following purposes deemed to be in the public interest or benefit:

Health Related Benefits and Services 

We may use your medical information to contact you with information about health- related benefits and services or about treatment alternatives that may
be of interest to you. We may disclose your medical information to a business associate to assist us in these activities.

We may use or disclose your medical information to encourage you to purchase or use a product or service by face-to-face communication or to provide you with promotional gifts.

Use and Disclosure of Certain Types of Medical Information

For certain types of medical information we may be required to protect your privacy in ways more strict than we have discussed in this notice. 

We must abide by the following rules for our use or disclosure of certain types of your medical information or purposes of use or disclosure of your medical information:

Disclosure of Medical Information for Treatment, Payment and Health Care Operations 

In order to disclose your medical information in the ways discussed above for treatment, payment and health care operations without specific authorization, we must obtain your general written permission.

HIV Information
We may not disclose HIV information unless required by law, pursuant to an authorization or the disclosure is to you or your personal representative; to an agent, employee or medical staff member of a health care provider, when the health care provider has received confidential HIV information during the course of your diagnosis or treatment by the health care provider, provided that the agent, employee or medical staff member is involved in the medical care or treatment of you; to individual health care providers involved in your care with an HIV-related condition or a positive test, when knowledge of the condition or test result is necessary to provide emergency care or treatment appropriate to you; to health care providers consulted to determine your diagnosis and treatment; to your insurer, to the extent necessary so that we may be reimbursed for health care services; to a peer review organization or committee, a nationally recognized accrediting agency or other government oversight bodies that we may legally disclose such information to; to persons whom we know you have had contact with and a physician reasonably believes that there is a significant risk of infection to the contact, but only after the physician has attempted to persuade you to disclose to the contact, the physician reasonably believes you will not inform the contact and the physician informs you of his or her intent to disclose the HIV information to the contact.

Alcohol and Drug Abuse Information 
We may not disclose your medical information that contains alcohol and drug abuse information except to you, your personal representative or pursuant to an authorization or as may otherwise be allowed by law.

Your Rights Regarding Medical Information About You Right to Inspect and Copy
You have the right to look at or get copies of your medical information, with limited exceptions. You must make a request in writing to obtain access to your medical information. You may obtain a form to request access by using the contact information listed at the end of this notice. You may also request access by sending us a letter to the address at the end of this notice. If you request copies, we will charge you a fee for copying and postage if you want the copies mailed to you. Contact us using the information listed at the end of this notice for a full explanation of our fee structure.

We may deny your request to inspect and copy in very limited circumstances as allowed by law. If you are denied access to your medical information, you may request that the denial be reviewed.  Another licensed health care professional chosen by the practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Disclosure Accounting
You have the right to receive a list of instances in which we or our business associates disclosed your medical information for purposes other than treatment, payment, health care operations, as authorized by you, and for certain other activities, since July, 2016. You must make a request in writing to request a listing of disclosures. You may obtain a form to request the accounting department by using the contact information at the end of this notice. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Contact us using the information listed at the end of this notice for a full explanation of our fee structure.


You have the right to request that we place certain restrictions on our use or disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Any agreement to additional restrictions must be in writing. You may obtain a form to request additional restrictions on the use or disclosure of your medical information by using the contact information listed at the end of this notice.

We will not be bound to the restrictions unless our agreement is signed by you and the appropriate office representative.

Confidential Communication
You have the right to request that we communicate with you about your medical information by alternative means or to alternative locations. For example, you might request that we contact you at work or by mail. You must make your request in writing. You may obtain a form to request alternative communications by using the contact information listed at the end of this notice. We must accommodate your request if it is reasonable, specifies the alternative means or location, and provides satisfactory explanation how payments will be handled under the alternative means or location you request.


If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. Your request must be in writing, and it must explain why the information should be amended. You may obtain a form to request an amendment by using the contact information listed at the end of this notice. We may deny your request if we did not create the information you want amended and the individual who provided the information remains available or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of  disagreement to be attached to
the information you wanted amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.

Electronic Notice

If you receive this notice on our web site or by electronic mail (e-mail), you are entitled to receive this notice in written form. Please contact us using the information listed at the end of this notice to obtain this notice in written form.

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed at the end of this notice. If you are concerned that we may
have violated your privacy rights, or you disagree with a decision we made about access to your medical information or in response to a request you made to amend or restrict the use or disclosure of your medical information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact: Jay Berger, CEO and owner

Telephone: (866) 505-5518

Address: Rehab Smarter, 4541 Timbery Drive, Jefferson, MD 21755

My electronic signature below indicates that I understand and accept the content of this form.

By signing below you have read, understood, and accepted all the information contained in this document.

__________________________________________________________________    _  _  / _  _  / _ _ _ _




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