I hereby consent to the evaluation and treatment of my condition by a licensed physical and/or occupational therapist employed by Destination Rehab. The physical/occupational therapist will explain the nature and purposes of these procedures, evaluation, and course of treatment. The physical/occupational therapist will inform me of expected benefits and complications, and any discomforts, and risk that may arise, as well as alternatives to the proposed treatment and the risk and consequences of no treatment.

Assignment of Benefits and Insurance Proceeds – I authorize payment of medical benefits to Destination Rehab for services rendered. Destination Rehab will make reasonable effort to collect insurance proceeds by completing insurance forms and sending the forms to the insurance company. Completion of such forms and/or the acceptance of assignment of insurance benefits does not relieve the undersigned of the obligation to pay the amount owed for physical/occupational therapy. I understand that I have been urged to contact my own insurance company to verify my benefits and the benefits discussed between myself and Destination Rehab are not guaranteed. I understand that I am responsible for all remaining costs including self-pay charges regardless of what was initially discussed and can request a Good Faith Estimate at any time.

Patient Information Consent Form (HIPAA) – I have been offered a copy of Destination Rehab’s Notice of Information Practices. I understand that Destination Rehab may use or disclose my personal health information for the purpose of carrying out treatment, obtaining payment, evaluating the quality of service provided, and any administrative operations related to treatment or payment. I understand that I have the right to request restrictions, in writing, regarding how my personal health information is used and disclosed for treatment, payment, and administrative operations. I hereby consent to the use and disclosure of my personal health information for purposes as noted in Destination Rehab’s Notice of Information Practices. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time, at which point Destination Rehab has 30 days to respond to my request.

Release of Information – I hereby authorize the release of information necessary to file claims with my insurance company. I permit a copy of this authorization to be used in place of the original.

Opt-In Agreement – By completing this form, I am agreeing to receive automated appointment confirmations via call, text message, and/or email, and that my email will be added to the email newsletter list managed by Destination Rehab. I understand I can request to opt-out at any point and my contact information will never be sold, rented or leased to any third-party ad companies nor will my information be provided to any third party individual, government or company at any time unless compelled to do so by law.

Cancellation Policy – I understand that each late cancellation I make (within 24 hours of my appointment time) costs Destination Rehab $150-200 each missed appointment. I understand that I will be allowed 3 freebie late cancellations, after which I will be temporarily moved to week-of scheduling. Once I have been consistent with week-of scheduling, I understand I will then be moved back to Destination Rehab's advanced scheduling list. In addition, to help ease the burden of my missed appointments I will be offered a chance to donate to Destination Rehab to help cover the lost funds. I understand the donation is not required and will be handled in a secure format.

I have read and understand the above consents, assignment of benefits, release of information, and designated individuals’ authorization above.

Full Assumption of Risk and Release of Liability Related to Participation in Activities Form

READ CAREFULLY BEFORE SIGNING. THIS FULL RELEASE IS AN ENFORCEABLE CONTRACT BETWEEN YOU AND DESTINATION REHAB, AN OREGON NONPROFIT CORPORATION WITH 501(c)(3) STATUS.  IT INCLUDES A RELEASE OF LIABILITY AND WAIVER OF CERTAIN LEGAL RIGHTS.  THIS FULL RELEASE COVERS ALL ACTIVITIES OF DESTINATION REHAB IN WHICH YOU PARTICIPATE FOLLOWING THE DATE YOU SIGN BELOW.

In consideration of being allowed to learn from and participate in any of the activities or programs (collectively “Activities”) sponsored by Destination Rehab (the “Organization”), you acknowledge and agree as follows:

1.            POTENTIAL RISKS.  Participation in Activities involves risks.  It is not possible to compile a complete list of all risks.  However, by signing this form, you acknowledge your full understanding that your participation in Activities involves a wide variety of risks, up to and including the possibility that you may suffer serious injury or illness, including permanent disability, paralysis, and death. 

2.            YOU ASSUME ALL RISKS & CERTIFY APPROPRIATE MEDICAL CONDITION.  You fully understand and acknowledge that you voluntarily, knowingly, and freely assume and take full responsibility for all risks, known and unknown, related to your participation in Activities, and you further acknowledge that you are entirely responsible for deciding whether to participate in any Activities with Organization and for deciding in which Activities you can safely participate. For some, but not all, participants, one of the Organization’s physical or occupational therapists has provided an evaluation and suggested these Activities because they believe that the potential benefit outweighs the risk that is always inherent in any physical activity. However, regardless of whether you have been evaluated by one of the Organization’s therapists or not, you acknowledge that this recommendation does not nullify the inherent risk in the Activities or any other part of this Agreement. You also acknowledge that you are aware of your physical condition and capabilities and believe that you are physically capable of participating in Activities. You understand and warrant that if at any time you believe any condition to be unsafe, you reserve the right, without penalty, financial or otherwise, to immediately discontinue further participation in Activities and bring such condition to the attention of Organization’s management.

3.            THE FOLLOWING ORGANIZATIONS AND PERSONS ARE COVERED BY THIS FULL RELEASE.  The persons and Organizations covered by this Full Release include:  Organization and its directors, officers, members, staff, employees, volunteers, assigns, agents, contractors, representatives, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, the owners, operators, and lessors of premises on which the Activities take place (“Agents”).

4.            YOU RELEASE ALL CLAIMS AGAINST ORGANIZATION AND ITS AGENTS.  You hereby agree for yourself and for your heirs, relatives, next of kin, representatives, estate, agents, and assigns, that you will not hold liable Organization or any of its Agents, and that you will waive and release any and all claims, actions, suits, demands, judgments, settlements, costs, and expenses, including reasonable attorneys’ fees and expenses, and liabilities of every kind and character whatsoever against them (“Claims”) resulting from any of the following (“Losses”): Damages to, or loss of, your property; your injury or death; or any other losses, costs, and damages, including those that are not readily foreseeable, which result from or arise in connection with your participation in any of the Activities of Organization including as a result of the action or inaction of other participants in Activities or the negligence of Organization or any of its Agents, other than that which results from the gross negligence, wanton or willful misconduct, or reckless or intentional conduct of Organization or its Agents.  You understand that this waiver includes a waiver of liability for acts of negligence.  In addition, you agree to indemnify Organization and its Agents for any Claims made against them, on your behalf or otherwise, as a result of any Losses.  In addition, Organization and its Agents shall not be liable for any Losses that occur while traveling to or from Organization Activities, or from place to place during Organization Activities, whether by Organization’s vehicle, your vehicle, or another participant’s or volunteer’s vehicle, other than that which results from gross negligence, wanton or willful misconduct, or reckless or intentional conduct of Organization or its Agents. Nothing in this release imposes liability upon Organization or its Agents for any losses or damages caused solely by third parties, including other participants in Organization’s Activities.

5.            IF YOU ARE A PARENT OR LEGAL GUARDIAN OF ANY PARTICIPANT WHO IS YOUNGER THAN 18 (“CHILD”), ON WHOSE BEHALF YOU ARE SIGNING THIS FORM, YOU ASSUME ALL RISKS AND RELEASE ALL CLAIMS ON BEHALF OF YOUR CHILD.  If you are the parent or legal guardian of a Child on whose behalf you are signing this form, you assume all risks and release all Claims on behalf of your Child and your Child’s heirs, relatives, next of kin, representatives, estate, agents, and assigns in the same way and to the same extent as you do for yourself in this Full Release.  Further, wherever the terms “I,” “me,” “my,” “myself,” “you,” or “your,” are used in this Full Release, those terms shall be interpreted to cover both yourself, where applicable, and the Child participant for whom you are signing.

6.            IF YOU CAUSE DAMAGE TO ANY ACTIVITY SITE, YOU AGREE TO PAY FOR ITS REPAIR.  If you cause damage to the Activity site (including damage to a building structure, equipment, or natural features such as trees and slopes), regardless of what entity or individual owns the Activity site, you agree that you will pay all costs and expenses associated with its repair or replacement (“Repair Costs”), including the costs of collection of the Repair Costs, which may include court costs and attorneys’ fees. 

7.            HELMET USE. By signing this Full Release, you agree to use a helmet when participating in the following activities: Alpine skiing, cycling outdoor rock climbing, snowboarding, white water kayaking, white water river rafting, and any other activity when directed by Organization or its Agents. You agree that you understand that a helmet is in no way a guarantee of safety and that no helmet can protect the wearer against all foreseeable impacts to the head and that the activities can expose you to forces that exceed the limits of protection provided by a helmet. You agree to assume full responsibility for complying with this paragraph and that Organization and its Agents shall not be liable for any injury or damage resulting from your failure to use a helmet.

8.            SEVERABILITY, MODIFICATION, AND WAIVER.  If any provision of this Full Release, or the application of a provision to any person or circumstance, is held invalid, the remainder of this Full Release, or the application of that provision to other persons or circumstances, must not be affected thereby. You agree that this Full Release may only be modified in writing, signed by both of the parties, and a waiver of any provision shall not be construed as a modification of any other provision herein or as a consent to any subsequent waiver or modification.

9.            GOVERNING LAW. This Full Release shall be interpreted according to the laws of the State of Oregon, and the parties consent to the personal jurisdiction of the Deschutes County Circuit Court in the State of Oregon. Nothing in this article shall preclude the parties from attempting to resolve conflicts through mediation or arbitration.

THIS FULL RELEASE IS INTENDED TO PROTECT THE ORGANIZATION AND ITS AGENTS (LISTED IN PARAGRAPH 3) FROM LIABILITY FOR INJURIES TO YOU, YOUR CHILDREN, AND YOUR PROPERTY TO THE MAXIMUM EXTENT ALLOWED BY OREGON LAW. 

 

The undersigned has/have read this Full Release and understand its terms.  This Full Release is executed freely and voluntarily, with full understanding that the undersigned is/are giving up substantial legal rights.

DESTINATION REHAB MEDIA RELEASE AGREEMENT

I give Destination Rehab and its partner organizations/companies, assigns, licensees, and legal representatives (“Organization”) the irrevocable right to use my/my minor child’s name, image, likeness, voice, quotes, diagnosis, and/or other information (“My Image and Likeness”) in any and in all forms of media (including print, film, photographs, digital recordings, and online) now and in the future for the purpose of public education, marketing, and other uses as Organization see fit. I also agree that this releases Organization from any and all monetary obligations for use of My Image and Likeness, and that Organization may transfer, use, or cause to be used My Image and Likeness for any exhibitions, public displays, publications, commercials, art and advertising purposes, television programs, and internet without limitations or reservations.

By signing this form:

• I authorize the above medical provider/facility/entity directly associated in my medical care to release my protected health information, including medical records, and/or a summary or narrative of my care, to DESTINATION REHAB, PO Box 8316, Bend, OR 97708, or via fax   971 242 4088.
• I authorize DESTINATION REHAB to release my protected health information, including medical records, and/or a summary or narrative of my care, to the above provider/facility/entity.

Items are scored between 0-100. A lower score indicates no confidence, higher indicates more confidence.

Scores less than 67 indicate risk of falling (Lajoie et al)

Step 1: Choose how well you perform each task.

Step 2: Choose how important each task is to you.

This questionnaire has been designed to give your therapist information as to how your BACK PAIN has affected your ability to manage in everyday life.

Please answer every question by choosing the option that best describes your condition today. We realize you may feel that two of the statements may describe your condition, but do your best to narrow it down to one option.

All times and distances are recorded in the 'performance' column. The corresponding score for each item is then selected and each column is then subtotaled. Subtotals are then added to calculate the HiMAT score. Higher scores indicate higher level of mobility.

Rules

Subject Suitability: The HiMAT is appropriate for assessing people with high-level balance and mobility problems. The minimal mobility requirement for testing is independent walking over 20mins w/o gait aids. Orthoses are permitted.

Item Testing: Testing takes 5-10mins. Patient are allowed 1 practice trial for each item.

Instruction: Patients are instructed to perform at their maximum safe speed except for the bounding and stair items.

 

Walking: The middle 10 meters of a 20 meter trial is timed. 

Walking backward: As for walking.

Walk on toes: As for walking. Any heel contact during the middle 10 meters is recorded as a fail.

Walk over obstacle: As for walking. A house brick is placed across the walkway at the midpoint. Patients must step over the brick without contacting it. A fail is recorded if patients step around the brick or make contact with the brick.

Run: The middle 10 meters of a 20 meter trial is timed. A fail is recorded if patients fail to have a consistent flight phase during the trial.

Skipping: The middle 10 meters of a 20 meter trial is timed. A fail is recorded if patients fail to have a consistent flight phase during the trial.

Hop Forward: Patient stands on their more affected leg and hop forward. The time to hop 10 meters is recorded.

Bound (affected): A bound is a jump from one leg to the other with a flight phase. Patients stand behind a line on their less affected leg, hands on hips, and jump forward landing on their more affected leg. Each bound is measured from the line to the heel of the landing leg. The average of three trials is recorded.

Bound (less affected): Patients stand behind a line on their more affected leg, hand on hips, and jump forward landing on their less affected leg. The average of three trials is recorded.

Up Stairs: Patients are asked to walk up a flight of 14 stairs as they normally would and at their normal speed. The trial is recorded from when the patient starts until both feet are at the top. Patients who use a rail or a non-reciprocal pattern are scored on "Up Stairs Dependent". Patients who ascend the stairs reciprocally without a rail are scored on the "Up Stairs Independent" and get an additional 5 points, scoring "Not dependent on rail or non-reciprocal pattern" on "Up Stairs Dependent".

Down Stairs: As for Up Stairs.

This questionnaire evaluates the effect of dizziness and/or balance problems on your ability to do things. Please rate your difficulty (if any) on each item. If you do not perform a particular activity or it is not part of your lifestyle, check NA (not applicabl).

 

Due to your dizziness/imbalance, how much difficulty did you have recently in:

Scoring: Higher scores indicate decreased frequency of leaving their home.

Question 1: The question asks about going to places outside the room where they usually sleep. This includes other rooms of the home such as the bathroom, kitchen, den, living room, etc. A person would only answer "No" to this question if they had been bed-bound for the last 3 days.

Question 2: This includes going to, or through, places immediately outside the home area but still adjacent to the home. These places include a porch, deck, patio, garage, or hallway of an apartment building (etc.). The places covered by this question don't have to be destinations. For example, a person going to their mailbox or down the block would obviously pass through one, or more, of these places and should answer "Yes".

Question 3: This includes going to, or through, places outside the home area and into places immediately surrounding the home such as the yard, driveway, sidewalk, courtyard, or parking lot. As in the previous question, a person going through these places on their way to a more distant destination should answer "Yes" to this question.

Question 4: This includes going to, or through, places beyond the property where their home is located. For homeowners, this refers to places beyond the property line. For those living in city apartments, this refers to places beyond the immediate block. For rural areas, this includes leaving the property lines.

Question 5: This includes going to, or through, places outside the neighborhood surrounding the home. In a city, this would be places beyond the surrounding 5 blocks. In a suburban area this refers to places about 3 streets from the home. For sparsely populated rural areas, this includes going to places on the other side of the closest neighbors.

Question 6: This includes going to, or through, places outside the town or community area nearest the home. This refers to places outside a particular sub-region of the city. This could be areas with a distinct name, or city areas such as east, west, north, or south. For rural areas, this includes going to places on the other side of the nearest town.

Question 7: This includes going to, or through, places on the other side of the county line (where substantial travel is involved) or to places on the other side of a large city. Respondents living near a county line where crossing into another county does not constitute a significant distance should not respond "Yes" here. To aid in standardization of the instrument, one could use a 20-mile radius as a guideline to answering questions of clarification on Item 7, especially for rural residents.

Question 8: This includes going to, or through, places over the state line. People living close (less than 20 miles) to the state line should not answer "Yes" to this question unless they traveled a substantial distance (more than 20 miles) into a neighboring state.

Question 9: The region of the country should be specified site-specifically, and the appropriate states listed. By this region, we mean the states of Oregon and Washington, & Idaho.