Authorization for Occupational Therapy Services

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Consent for Treatment

I, _________________________, hereby authorize [Practice Name] and its licensed occupational therapists to provide occupational therapy evaluation and treatment services. I understand that occupational therapy may include:

• Assessment of daily living activities and functional capabilities
• Therapeutic exercises and activities
• Manual therapy techniques
• Use of adaptive equipment and assistive devices
• Training in compensatory strategies
• Home exercise program instruction

Financial Agreement

I understand that:

• I am responsible for payment of all charges not covered by insurance
• Insurance benefits quoted are not a guarantee of payment
• Copayments and deductibles are due at time of service

Release of Information

I authorize the release of medical information necessary to:

• Process insurance claims
• Communicate with referring healthcare providers
• Coordinate care with other healthcare professionals

Acknowledgment

• I have read and understand the above information
• I have had the opportunity to ask questions
• I agree to participate in the development of my treatment plan

Signature: ______________________ Date: _______________

Witness: ________________________ Date: _______________

Office Use Only

OT Provider: ____________________ License #: ____________ Initial Evaluation Date: __________ Diagnosis Code(s): ______________