Healthcare PT Packet

Healthcare PT Packet

Patient Information

Emergency Contact

Insurance Information

If subscriber is not the patient, provide subscriber date of birth and relationship to patient: DOB Relationship

Medical History & Current Condition

Do you use assistive devices? Check all that apply: Walker   Cane   Wheelchair   None

Consent for Physical Therapy Treatment

I, the undersigned, authorize licensed physical therapists and physical therapist assistants performing under their supervision to provide evaluation and treatment appropriate to my condition, including but not limited to therapeutic exercise, manual therapy techniques, modalities (heat, ice, electrical stimulation), and functional training. I understand that the nature of physical therapy and associated interventions has potential benefits and risks.

Risks: While most patients benefit from physical therapy, foreseeable risks include increased pain, tissue soreness, skin irritation, sprain/strain, and in rare instances, aggravation of underlying medical conditions. I acknowledge that no guarantee of outcome or cure has been made.

Benefits: Expected benefits include reduced pain, improved mobility, increased strength, and enhanced functional capacity. The care plan will be tailored to my specific diagnosis and goals.

I understand that I have the right to ask questions and to refuse or withdraw consent at any time. I agree to follow the home exercise program and to inform my therapist of any change in my health status, new symptoms, or adverse reactions to treatment.

By signing below I authorize the physical therapy services described above and consent to the performance of such services as deemed necessary by my treating therapist.

HIPAA Privacy Acknowledgment & Authorization

I acknowledge that I have been offered or provided with the facility's Notice of Privacy Practices describing how my protected health information (PHI) may be used and disclosed and my rights with respect to that information. I authorize the use and disclosure of my PHI, including billing and clinical information, to third parties for treatment, payment, and healthcare operations as required. This authorization includes communication with my insurance carrier and other health care providers for coordination of care and claims processing.

I specifically authorize the release of medical records related to my physical therapy care to the following persons or entities when necessary for treatment or payment purposes:

This authorization will expire on:

I acknowledge receipt of the Notice of Privacy Practices and authorize release/use of my PHI as described above.

Financial Responsibility & Assignment of Benefits

I assign to the provider all rights and claims for reimbursement for services rendered and direct that payment be made on my behalf to the provider. I understand that I am financially responsible for all charges not covered by insurance, including deductibles, co-payments, co-insurance, and services deemed not reasonable or necessary by my insurer.

I authorize the release of any medical or other information necessary to process claims and to facilitate payment for services. I understand that billing errors may be adjusted and that I will be notified of balances due.

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

Cancellation & No-Show Policy

Appointments missed without 24 hours advance notice may be subject to a cancellation fee. Repeated late cancellations or no-shows may result in discharge from care. Exceptions may be made for emergencies at the provider's discretion.

Patient Certifications

By signing this packet I certify that the information I have provided is complete and accurate to the best of my knowledge. I authorize treatment, the release of necessary information for treatment and payment, and accept financial responsibility as indicated. I have had the opportunity to ask questions and have received satisfactory answers regarding my care and this authorization.

If signing on behalf of the patient, I certify that I am the lawful representative and have authority to execute this document on the patient's behalf.

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