Physical Therapy Services Agreement and Informed Consent

Patient Information

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

1. Consent for Treatment

I, the undersigned, give consent to [PRACTICE NAME] and its physical therapy staff to provide physical therapy evaluation and treatment as prescribed by my physician and/or recommended by my physical therapist.

2. Financial Agreement

• I understand that I am responsible for any charges not covered by my insurance
• Co-payments are due at the time of service
• Estimated patient responsibility: $_______ per visit
• Cancellation fee for less than 24-hour notice: $_______

3. Treatment Policies

Attendance and Cancellation

• 24-hour notice is required for cancellations
• Three no-shows may result in discharge from therapy
• Consistent attendance is crucial for optimal outcomes

Patient Responsibilities

• Follow prescribed home exercise program
• Report any changes in medical condition
• Wear appropriate clothing for treatment
• Maintain personal hygiene

4. Privacy Practices

I acknowledge receipt of the Notice of Privacy Practices (HIPAA) and consent to use and disclosure of protected health information for treatment, payment, and healthcare operations.

5. Release of Information

I authorize release of information to:

• Insurance providers
• Referring physician
• Other healthcare providers involved in my care

Signatures

Patient/Guardian: _________________ Date: _________ Therapist: ______________________ Date: _________

Office Use Only

PT Initial Evaluation Date: _________ Diagnosis Code(s): _______________ Treatment Plan: _________________