Healthcare Rehab Disclosure

HEALTHCARE REHAB DISCLOSURE

Patient Information

Date of Birth:    Gender:

Primary Phone:    Secondary Phone:

Insurance and Billing

Policy / ID Number:    Group Number:

Medical History & Current Status

Program / Services to Be Provided

The patient will receive rehabilitation services appropriate to the identified needs. Services authorized for this episode include (check all that apply):

Physical therapy

Occupational therapy

Speech therapy

Behavioral therapy / Counseling

Group therapy / education sessions

Risks, Benefits, and Alternatives

I understand that the anticipated benefits of the rehabilitation program include improvement or stabilization of physical, cognitive, or behavioral function, reduction of symptoms, and improved ability to perform daily activities. These outcomes cannot be guaranteed.

I understand the material risks and potential adverse effects include, but are not limited to: transient increases in pain or fatigue; skin irritation; falls or injury during therapy; psychological distress during behavioral interventions; medication side effects if medications are part of care; and the possibility that no clinically significant improvement will occur.

Reasonable alternative treatment options, including no treatment, reduction of service intensity, or referral to other providers, have been explained and discussed with me when applicable.

Confidentiality, Mandated Reporting, and Information Sharing

Patient health information created or received in connection with these services is subject to privacy protections. Exceptions that permit or require disclosure without authorization include: imminent risk of serious harm to self or others, suspicion of child or elder abuse or neglect, certain court orders, or other disclosures required by law.

By signing this disclosure, I authorize the program to share treatment information with my insurance carrier, referring provider, and other designated providers for purposes of treatment, payment, and healthcare operations. I understand that information released to payers may include clinical notes, diagnoses, and treatment plans necessary for claims processing.

Financial Responsibility and Assignment

I acknowledge that I am responsible for applicable co-payments, deductibles, and services not covered by my insurance. The provider may bill my insurance and, where applicable, seek reimbursement from third parties. I authorize assignment of benefits to the provider unless otherwise specified in writing.

Consent and Authorization

I have read and understand this Healthcare Rehab Disclosure. I have had the opportunity to ask questions and receive satisfactory answers. I consent to the provision of the rehabilitation services described above and authorize staff to perform assessments, treatments, and interventions deemed appropriate by the treating clinician.

Initial to indicate understanding and agreement:    Initials:

I authorize the following specific actions (check all that apply):

Administration of prescribed medications related to treatment

Telehealth or remote therapy sessions when offered

Use of clinical photographs or videos for treatment documentation (not for marketing) unless declined

Right to Withdraw and Complaints

I understand that my participation in the program is voluntary. I may withdraw consent for treatment or revoke this authorization at any time, provided the revocation is in writing, except to the extent that actions have been taken in reliance on this authorization. Complaints or concerns about care may be directed to program management; such complaints will not affect my access to services.

Authorization Term

This authorization expires on:

Acknowledgment of Receipt

I acknowledge receipt of this disclosure and that I have been provided an opportunity to discuss the contents with a clinician or administrative representative. I understand that this document explains the nature of treatment, associated risks, financial obligations, and limits to confidentiality.

Patient / Guardian printed name:

Relationship to patient (if signing as guardian or representative):

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