Physical Therapy Authorization for Treatment and Informed Consent

Patient Information

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

Consent for Treatment

I, the undersigned, give my consent to receive physical therapy evaluation and treatment from [CLINIC NAME] and its licensed physical therapists and physical therapy assistants.

Authorization Statements

1. Treatment Authorization

   • I understand that physical therapy may include hands-on therapeutic procedures and various modalities
   • I acknowledge that no guarantees have been made regarding the outcome of treatment
   • I understand that treatment may cause temporary soreness or exacerbation of symptoms

2. Financial Agreement

   • I authorize direct payment of medical benefits to [CLINIC NAME]
   • I understand I am financially responsible for any charges not covered by my insurance
   • I agree to pay all copayments, deductibles, and coinsurance amounts

3. Release of Information

   • I authorize the release of medical information necessary for treatment and billing
   • I permit sharing of clinical information with my referring physician and insurance provider

4. Cancellation Policy

   • I acknowledge that 24-hour notice is required for appointment cancellation
   • I understand that a fee may be charged for missed appointments or late cancellations

Acknowledgment

I have read and understand the above information and agree to the terms and conditions.

Patient/Guardian Signature: _________________ Date: __________

PT Witness Signature: ______________________ Date: __________

Office Use Only

Chart #: _____________ Insurance Verification: □ Yes □ No Notes: _________________________________________________