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ONE STOP Physical Therapy & Wellness
RELEASE OF INFORMATION AND CONSENT FOR TREATMENT FORM
I am aware of my diagnosis and give permission to receive treatment from One Stop Physical Therapy, Wellness and Home Safety (Provider) clinician(s).
Physical Therapy (PT) is a client care service provided in response to a wide range of medical care needs of clients of all ages regardless of gender, color, ethnicity, creed or disability. The purpose of PT is to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis and intervention. PT treatment may consist of rehabilitative procedures, mobilizations, massage, exercises and physical agents to aid the client in achieving their maximal potential for recovery within their capabilities. The PT can also provide Wellness rehabilitation via exercises and modalities under direct supervision from a skilled clinician. The Wellness program implementation is designed according to client or client's Power of Attorney choices.
I give permission to Provider and its affiliates to release information, verb al and written, contained in my medical record, and other related information, to my insurance company, rehabilitation nurses, case managers, attorneys, employers, school, related healthcare providers, assignees and/or beneficiaries, and all affiliates to obtain medical records and/or professional information from my physician/provider or other medical professionals as it relates to my treatment.
ASSIGNMENT OF BENEFITS
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