NSR — Consents, HIPAA, Financial & Cancellation Policy
Fields marked * are required. All information is kept strictly confidential and protected under HIPAA.

1. Consent to Treat & Assignment of Benefits

I voluntarily authorize and consent to physical therapy and/or occupational therapy services provided by Next Step Rehab and/or as directed by my referring provider. I understand I have the right to ask questions before any treatment, including questions about risks, alternatives, and expected outcomes.

I assign payment for these services directly to Next Step Rehab. I authorize the filing of insurance claims and the release of health information necessary to process those claims. I accept responsibility for all co-pays, co-insurance, deductibles, and non-covered services. Checks payable to: Next Step Rehab.

Patient / Guardian Signature — Consent to Treat

2. HIPAA Notice of Privacy Practices Acknowledgment

I acknowledge that I have been offered a copy of Next Step Rehab's Notice of Privacy Practices (NPP), which describes how my Protected Health Information (PHI) may be used and disclosed. I am aware of my rights to: request restrictions on certain uses and disclosures; access my health records; request amendments to my records; receive an accounting of disclosures; and file a complaint with the U.S. Department of Health and Human Services if I believe my privacy rights have been violated.

Patient / Guardian Signature — HIPAA NPP Acknowledgment

3. Maryland CRISP Health Information Exchange

Next Step Rehab participates in CRISP(Chesapeake Regional Information System for our Patients), Maryland's statewide Health Information Exchange (HIE). CRISP enables authorized providers to securely share your medical records to improve coordination of your care. Participation is voluntary.

For more information: www.crisphealth.org  ·  To opt out by phone: 1-877-952-7477

CRISP authorization choice:
Patient / Guardian Signature — CRISP HIE Authorization

4. Authorization for Communication

I consent to Next Step Rehab using automated telephone calls, SMS text messages, and/or email to communicate appointment reminders, billing information, and general healthcare messages. I understand that providing contact information is not a condition of receiving services, and I may revoke this consent at any time by contacting the office in writing.

Communication authorization:

5. Release of Medical Information

I authorize Next Step Rehab to discuss my protected health information (PHI) with the following authorized individuals. This authorization does not expire unless I revoke it in writing.

6. Financial Policy

Payment for services is due at the time services are rendered. Next Step Rehab will make a good-faith effort to verify your insurance benefits prior to your first visit; however, verification of benefits does not guarantee payment. You are responsible for all co-pays, co-insurance, deductibles, and services not covered by your insurance plan. A $35.00 returned check fee applies to any returned checks. Monthly statements will be issued for outstanding balances. Checks payable to: Next Step Rehab.

Patient / Guardian Signature — Financial Policy Agreement

7. Telehealth Alternative

Before cancelling an appointment — consider a TELEHEALTH VISIT instead. If you are unable to receive your therapist at home on a scheduled day, we can convert your in-home visit to a secure, HIPAA-compliant video session at NO additional cost. This keeps your recovery on track and avoids all cancellation fees.

Telehealth visits are appropriate for:

8. Cancellation, No-Show & Scheduling Policy

Our therapists travel directly to your home. Reliable scheduling protects your recovery and respects the time of other patients. Please contact us at least 24 hours in advance to cancel or reschedule — or request a telehealth visit instead.
Situation Fee Action
No-Show — Therapist arrived; patient unavailable / unreachable $50.00
Not billable to insurance 		Documented. Repeated no-shows may result in discharge from practice.
1st Late Cancellation — Less than 24 hours' notice WAIVED
Professional courtesy, first time only 		Documented. Patient receives written copy of this policy.
2nd Late Cancellation $30.00
Not billable to insurance 		Written notice: next occurrence results in discharge with referral.
3rd Late Cancellation or repeated non-compliance DISCHARGE Written notice provided with referrals for continuity of care.

By signing below, I confirm I have read, understand, and agree to the Cancellation, No-Show, and Scheduling Policy above. I understand that telehealth was offered as an alternative to cancellation.

Patient / Guardian Signature — Cancellation Policy Agreement

9. Consent to Photograph, Video Record & Use of Likeness

Purpose of Photography & Video Recording

Next Step Rehab may request to take photographs or video recordings of you during the course of your physical or occupational therapy treatment. Please review each potential use below and indicate your preference.

Purpose of Use I Consent ✔ I Do Not Consent ✗
Clinical Documentation
Documenting posture, movement, wounds, or progress for your medical record only. Never shared externally.
Professional Education & Staff Training
Used to train Next Step Rehab staff or students in a de-identified or anonymized format.
Marketing & Promotional Materials
Used on the Next Step Rehab website, social media, printed materials, or other public marketing. Your name would be included only with separate written permission.
Research & Quality Improvement
Used in clinical research, outcome studies, or quality improvement projects in a de-identified format. Any identifiable research use requires a separate IRB-approved consent.
Home Exercise Program (HEP) Videos
Video recordings made solely for your personal use to demonstrate prescribed exercises. Sent only to you via secure means and not stored in the medical record.
Your rights: This consent is entirely voluntary. Refusing consent for any purpose will not affect the quality of your care in any way. You may withdraw this consent at any time by notifying your therapist or contacting our office in writing. Withdrawal does not affect uses already made prior to revocation. All photography and video recording is conducted with your knowledge and in your presence only.
Patient / Guardian Signature — Consent to Photograph & Video Recording

Form 3 of 11  ·  Next Step Rehab Patient Intake Suite  ·  www.nextstep-rehab.com