Occupational Therapy Service Agreement and Treatment Contract

Agreement Details

This agreement is made between:

Provider: [Occupational Therapist Name], [Credentials] License Number: [Number]

Patient: [Patient Name] Date of Birth: [DOB]

1. Services

The occupational therapist agrees to provide the following services:

• Comprehensive evaluation and assessment
• Development of individualized treatment plan
• Regular therapy sessions as prescribed
• Progress monitoring and documentation
• Home exercise program development

2. Financial Responsibilities

Payment Terms

• Session fee: $[Amount] per [duration] session
• Insurance billing: [Terms]
• Copayments due: At time of service
• Cancellation fee: [Amount] if less than [hours] notice

3. Attendance Policy

• 24-hour notice required for cancellations
• Three consecutive no-shows may result in discharge
• Consistent attendance is essential for treatment success

4. Patient Responsibilities

The patient agrees to:

• Attend scheduled sessions promptly
• Participate actively in treatment
• Follow prescribed home exercise program
• Provide accurate medical history
• Inform therapist of changes in medical condition

5. Privacy and Confidentiality

• All treatment information is confidential
• Records released only with written consent
• Compliance with HIPAA regulations

6. Duration and Termination

• Initial treatment period: [Duration]
• Reassessment every [Number] weeks
• Either party may terminate with written notice

Signatures

Patient/Guardian: _______________ Date: ______

Occupational Therapist: _________ Date: ______