Healthcare Physical Therapist Agreement

HEALTHCARE PHYSICAL THERAPIST AGREEMENT

This Physical Therapist Agreement (the Agreement) establishes the terms under which physical therapy services will be provided to the patient identified below by the treating physical therapist or clinic identified below. Agreement Date:

Patient Information

Date of Birth:    Gender:

Primary Phone:    Email:

Relationship:    Phone:

Provider Information

License/Provider ID:    Clinic Phone:

Insurance Information

Policy Number:    Group Number:

Medical History & Current Condition

Treatment Plan & Consent

Proposed Treatment: The provider will perform a physical therapy evaluation followed by therapeutic interventions appropriate to the patient's condition, which may include but are not limited to manual therapy, therapeutic exercise, neuromuscular re-education, modalities, and functional training. Anticipated frequency: ; Estimated duration: .

Risks and Benefits: I understand that physical therapy generally carries minimal risk but may include soreness, increased pain, aggravation of pre-existing conditions, and rare but serious complications. Benefits may include reduced pain, improved function, and prevention of further injury. There is no guarantee of specific results.

I authorize the treating physical therapist and staff to provide physical therapy as described above and to communicate with other treating providers as necessary for care coordination.

I consent to evaluation and treatment by the physical therapist and authorized staff.

I acknowledge that the risks, benefits, and alternatives have been explained and I have had the opportunity to ask questions.

Financial Responsibility & Insurance Billing

Patient financial responsibility includes co-payments, deductibles, co-insurance, and charges not covered by insurance. All co-payments are due at the time of service. The patient agrees to pay for services not reimbursed by insurance.

Assignment of Benefits: By checking below, I authorize the provider to bill my insurance and assign benefits to the provider to the extent permitted by my plan.

I authorize assignment of insurance benefits and direct payment to the provider.

Cancellation Policy: Appointments cancelled with less than 24 hours' notice may be subject to a late cancellation fee. Repeated missed appointments may result in discharge from care.

HIPAA & Privacy Authorization

I acknowledge receipt of the provider's Notice of Privacy Practices and authorize the release of my protected health information as necessary for treatment, payment, and health care operations. I authorize release of information to my insurer and to persons listed below as necessary for care coordination.

Authorization Expiration: Unless otherwise revoked in writing, this authorization will expire on .

I acknowledge the provider's privacy practices and authorize use/disclosure of my protected health information as described above.

Limitations, Termination & Governing Law

Termination: Either party may terminate this Agreement with written notice. Provider may discharge the patient for non-compliance, non-payment, or missed appointments.

Liability: To the extent permitted by law, the provider's liability for any claim arising out of this Agreement is limited to the total amount paid by or on behalf of the patient for the services that are the subject of the claim. This limitation does not apply to gross negligence or willful misconduct.

Governing Law: This Agreement will be governed by the laws of the state where services are rendered.

Patient Certification

By signing below, I certify that the information I have provided is true and complete to the best of my knowledge. I understand the nature of the proposed physical therapy, the risks and benefits, my financial responsibilities, and my rights under applicable privacy laws. I consent to treatment and to the billing practices described above.

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