Healthcare Comp PT Form

Healthcare Comp PT Form

Patient Information

Patient Name:

Male Female Non-binary Other:

Emergency Contact

Employment / Injury Information

This injury/condition is work-related Claim/Claim Number:

Insurance Information

Medical History

Chronic Conditions (check all that apply): Hypertension Diabetes Heart disease Asthma / COPD

Prior physical therapy for this condition: Yes No

Presenting Complaint & Function

Consent to Physical Therapy Treatment

I consent to evaluation and treatment by licensed physical therapists and physical therapist assistants. Treatment may include hands-on manual therapy, therapeutic exercise, neuromuscular re-education, soft tissue mobilization, traction, electrical stimulation, heat/ice modalities, and other standard physical therapy procedures. I understand that potential risks include, but are not limited to, increased pain or discomfort, muscle soreness, bruising, skin irritation from modalities, and rare complications. I have been given the opportunity to ask questions about the proposed plan of care, alternatives, and expected benefits and risks.

I understand I may withdraw consent at any time and that withdrawal will not affect my right to future care or treatment. I agree to report any adverse reaction or unexpected change in my condition to the treating clinician immediately.

By checking this box I provide informed consent for the treatments described above and authorize the clinician to proceed.

HIPAA Acknowledgment & Release

I acknowledge receipt of the practice's Notice of Privacy Practices describing the uses and disclosures of my protected health information for treatment, payment, and healthcare operations. I authorize the release of my health information to other healthcare providers, referring physicians, insurance payers, and employers/claims administrators as necessary for treatment, payment, or claim adjudication related to this episode of care.

I authorize disclosure of my medical records for purposes of workers' compensation, disability determinations, and benefit administration as applicable. This authorization is valid until the authorization expiration date provided below unless revoked in writing earlier.

I acknowledge that I have been offered or provided the Notice of Privacy Practices and I authorize the uses and disclosures described above.

Release of Information & Assignment

I authorize release of information to the following parties as needed for treatment or payment (check all that apply):

Referring physician Insurance / Claims adjuster Employer / Workers' Compensation

I hereby assign benefits to the provider and authorize direct payment to the physical therapy practice for services rendered. I understand I am financially responsible for charges not covered by insurance, including co-payments, deductibles, and non-covered services.

I agree to the assignment of benefits and accept financial responsibility as described above.

Certification

I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I have read and understand the consent, authorization, release, and financial responsibility statements above. I understand that falsification of information may affect my care and billing.

Sign Now