Healthcare OT Packet

Healthcare OT Packet

Patient Information

Date of Birth:    Gender:

Primary Phone:    Secondary Phone:

Relationship:    Phone:

Insurance Information

Policy / ID Number:    Group Number:

Subscriber DOB:    Insurance Phone:

Medical History & Current Status

Use of assistive device(s): Walker Cane Wheelchair None

Functional Abilities & Occupational Needs

OT Evaluation & Treatment Consent

I authorize the provision of occupational therapy evaluation and treatment services as ordered by my referring clinician. Occupational therapy services may include evaluation, therapeutic exercise, neuromuscular re-education, manual therapy, adaptive equipment assessment, home safety evaluation, splinting, and caregiver education. I understand that the goals of occupational therapy are to restore, develop, or maintain functional skills and to enable safe participation in daily activities.

Risks and potential complications associated with OT interventions include, but are not limited to: temporary increases in pain or stiffness, fatigue, skin irritation from splints or tape, muscle soreness, and occasional injury despite precautions. Benefits may include improved function, reduced pain, increased independence, and reduced risk of further injury. No guarantee of specific outcomes is provided.

I acknowledge that I may refuse or discontinue treatment at any time. If I refuse recommended services, this may affect progress toward therapeutic goals and could increase risk related to the underlying condition. I accept responsibility to inform the therapist of changes in my medical condition, medications, or symptoms.

Financial Responsibility: I understand that I am responsible for payment of services not covered or denied by my insurer, including co-payments, deductibles, and services deemed non-covered. The provider may bill my insurance and, where permitted, assign benefits. I authorize release of information necessary to process claims and appeals.

HIPAA Authorization & Release of Information

By signing below I authorize the release of my protected health information to relevant healthcare providers, insurers, and designated representatives for purposes of treatment, payment, and healthcare operations related to occupational therapy services. This authorization includes medical records, evaluations, progress notes, functional status reports, and billing information.

I understand that this authorization is voluntary and that I may revoke it at any time in writing, except to the extent that action has been taken in reliance on this authorization. This authorization will expire on: .

I acknowledge receipt of the facility's Notice of Privacy Practices and understand my rights regarding the privacy of my health information, including the right to request restrictions and the right to request confidential communications.

Patient Authorization to Share Information with Family / Caregiver: I authorize release of information to the following persons:

Relationship:    Phone:

Therapy Goals & Plan (To be completed by therapist)

Recommended Frequency / Duration:

Patient Rights, Acknowledgements & Certification

I certify that the information provided on this packet is complete and accurate to the best of my knowledge. I understand that omission of material information may impact care and billing. I consent to the release of necessary clinical information to my insurer, referring providers, and other agents involved in my care as described above.

I acknowledge receipt of a copy of this document and understand my rights to ask questions about any of the information contained herein.

I understand that I may be billed for missed appointments or late cancellations in accordance with the provider’s cancellation policy and that my insurer may not cover all services provided.

Consent to Emergency Treatment: In the event of an emergency during a therapy session, I authorize therapists and staff to initiate appropriate emergency care and to contact emergency services as needed.

Acknowledgment of Privacy Practices: I acknowledge that I have been offered information regarding privacy practices.

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