Rehabilitation Services at OakBend/Ollin No Show/CancellationPolicy

Rehabilitation Services at OakBend Medical Center strives to provide each and every patient with personalized care and attention throughout their scheduled appointment time. In order to maintain this high level of care, it is very important that all patients attend their scheduled appointment time. If an appointment is scheduled but not attended, it takes a valuable appointment time away from other patients who have made it a priority to work towards their physical therapy goals. "No Show" is missing a scheduled physical therapy appointment without a call prior to that appointment to inform Rehabilitation Services at Oakbend . A"cancellation" is canceling a scheduled physical therapy appointment without giving 24 hours' notice. A " reschedule" is calling 24 hours prior to a scheduled physical therapy appointment to change that appointment to a different timeor day because of a conflict.

__ If a patient arrives more than 15 minutes late for their scheduled appointment, they may be asked to wait until the physical therapy staff can accommodate their late arrival 01 may be asked to reschedule their appointment.
__ If a patient "No Show" for more than one appointment, they will be seen when the physical therapy staff can accommodate their treatment without affecting other patient's quality of care.
__ If a patient "Cancels" any three appointments without giving 24 hours' notice to our staff, they will be seen when the physical therapy staff can accommodate their treatment without affecting other patient's quality of care.
__ After any three "No Shows or Cancellations" Rehabilitation Services at OakBend Medical Center reserves the right to discharge the patient from physical therapy. Our staff will inform the referring physician of the patient's non-compliance with attending their prescribed physical therapy. The patient must obtain a new prescription for physical therapy from their physician before being able to return.

We understand true medical emergencies do occasionally arise when an appointment cannot be kept and adequate notice is not possible. These situations will be considered on a case by case basis.



Patient Signature:


 Patient Information Sheet
 ​​​If no copy attached, complete next section:
 Patient Demographic Information
 Guarantor Demographic Information​​​
(if different than above)

 Emergency Contact/ Next of Kin Information
1st Contact

2nd Contact

 Outpatient Medical History / Subjective Information

 Medical History (Please check all that apply)


TB Screening
 Recent history of persistent fever?
 Recent history of night sweats?
 Recent history of unexplained weight loss?
 History of treatment or exposure to TB?
 Please list all operation you have had
  Please list any allergies to drugs, food, or environment

 Injury/Problem Information
 How and when did the injury or problem occur?


 Please rate your pain using a 0-10 scale
 0 = no pain at all, 5 = pain interferes with daily tasks, 10 = worst pain you can imagine

  Please rate your pain using a 0-10 scale
  0 = no pain at all, 5 = pain interferes with daily tasks, 10 = worst pain you can imagine
Best pain since onset?


 Physical Therapy Goals and Expectations?
 Employment History
 Activity and Exercise History
 To the best of my knowledge and belief, the information I have given is complete and true. I hereby give my consent to receive therapy services at OakBend Medical Center. I have received a copy of The Patient/Client Rights and Responsibilities Information Sheet

 Patient Signature:
Therapists Section:


Plans to address special learning factors/barriers (as identified):

 Therapist Signature:

 I hereby authorize
 to release health information to:
 Purpose of Disclosure 
Treatment Date:  

Health Information to be Released:



 I understand that some of my health information may include information relating to Human Immunodeficiency Virus (HIV) or Acquired Immunodeficiency Syndrome (AIDS), treatment for or history or drug and/or alcohol abuse, or mental/behavioral health/psychiatric care. I hereby give my consent to release this sensitive information:


I understand that this authorization will be valid for 180 days unless otherwise specified:

I, the undersigned, have read the above and authorize the staff of OakBend Medical Center to disclose such information as herein contained. I have the right to revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon. I understand that OakBend Medical Center may not condition treatment on my completion of this authorization form. I also understand that when this information is used and disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected. I hereby hold harmless the above named facility from all liability and damages resulting from the lawful release of my Protected Health Information.

 Signature of Patient/Parent/Guardian
 Authorization for Release of Information

OakBend Medical Center/OakBend Health System ("OakBend") is always pleased when patients are willing to communicate the stories, experiences, and information about the treatment received at OakBend. Sharing your story can help others who are interested in knowing more about the services provided by OakBend and can help OakBend promote its mission, vision, and values. This form is a part of our effort to protect your rights. If you have any questions or concerns, please talk to the person helping you withthe form. I authorize OakBend to disclose to media representatives and/or public affairs/relations representatives protected health information and information about me, my condition, or treatment for purposes of publications, fundraising, advertising, marketing, publicity, promotion, education, or publication in print, broadcast and electronic media, including social media. This authorization includes my likeness on photo, videotape and digital media. Briefly describe nature of project, including a description of what health/personal information will be involved and the audience or type of audience that may be involved:

This authorization also allows the media/public affairs/relations representatives to take photographs, films, audio and/or videotapes, interview me or publish information about me, and to use my likeness and information in an appropriate manner for the above project. List any limitations to the use of my information, photos, etc. here:

Signature of Individual or Legally Authorized Representative 

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