MOMS TREATING MOMS, LLC
Direct Access Consent Attestation and Medical Release Form
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CURRENT CARE AND ATTESTATION
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Please check one below:
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I understand that the current course of physical therapy will last no more than 5 days, and that further treatment for the above symptoms will be under the direction of a licensed healthcare practitioner. To receive additional physical therapy services beyond the 5 day period, I will be required to sign consent to send my initial evaluation to a licensed healthcare practitioner.
PRACTITIONER INFORMATION:
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I understand that the current course of physical therapy will last no more than 5 consecutive days, and that additional physical therapy care for the symptoms listed on this form shall only be upon the referral and direction of a licensed healthcare practitioner. To receive additional physical therapy services beyond this 5 day period, I will be required to sign consent to have my initial evaluation sent to the licensed healthcare practitioner named above.
I understand that that practitioner named above will be provided a copy of my initial evaluation and patient history within 5 days. I hereby consent to the release of my personal health and treatment records to the practitioner named above.
