Healthcare PTA Document

PATIENT TREATMENT AUTHORIZATION (PTA)

Patient Information

Date of Birth:    Gender: Male Female Other / Decline

Emergency Contact

Insurance Information

Medical History

Pregnancy status (if applicable): Pregnant Not Pregnant Unknown

Authorization for Treatment

I, the undersigned patient or legal representative, hereby authorize the licensed healthcare practitioners and staff of the treating facility to evaluate, perform, and provide physical therapy and related diagnostic and therapeutic services as deemed necessary by the clinician. Services included under this authorization may include, but are not limited to, therapeutic exercise, manual therapy, soft tissue modalities, electrical stimulation, wound care related to therapy, home exercise instruction, functional training, and assessment and reassessment associated with the course of care.

I understand that the purpose of the proposed treatment has been explained to me, and that no guarantee has been made regarding the results. I acknowledge that risks and potential complications associated with the treatment have been explained, including but not limited to increased pain or discomfort, muscle soreness, fatigue, skin irritation, aggravation of pre-existing conditions, and rare complications. I understand alternative treatment options, including no treatment, have been explained where applicable.

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

Financial Responsibility and Assignment

I authorize the treating facility and its billing agents to submit claims to my health insurer(s) on my behalf and to receive payment directly from such insurers for services rendered. I assign to the treating facility all rights to insurance benefits for services provided. I understand that I remain financially responsible for charges not covered by insurance, including deductibles, copayments, coinsurance, and services determined to be non-covered or not medically necessary.

I authorize the release of medical information necessary to process insurance claims and to coordinate care with other healthcare providers, facilities, or payers. This authorization includes release of records related to mental health, substance abuse treatment, HIV/AIDS status, and other protected health information when required for payment or continuity of care, to the extent permitted by law.

Release information to: Family/Household Member Other Healthcare Provider Insurance Carrier

If release to other party, name:

HIPAA Privacy Acknowledgment

I acknowledge that I have received or been offered a copy of the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights with respect to that information.

I acknowledge receipt of the Notice of Privacy Practices.

Expiration and Revocation

This authorization is effective upon the date signed and will remain in effect until: unless earlier revoked in writing by the patient or authorized representative. Revocation will not affect disclosures made prior to receipt of the revocation.

Effective date of authorization:

Acknowledgment and Certification

By signing below I certify that I am the patient or am authorized to act on behalf of the patient. I have read and understand the information on this form, I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction. I understand that I may withdraw this authorization at any time in writing except to the extent that action has already been taken in reliance on it.

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