Consent Direct Access - PA | Moms Treating Moms

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Direct Access Consent Attestation and Medical Release Form

CURRENT CARE AND ATTESTATION

Please check one below:

I understand that the current course of physical therapy will last no more than 30 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 30 day period, I will be required to obtain a referral from a licensed healthcare practitioner.

PRACTITIONER INFORMATION:

I understand that the current course of physical therapy will last no more than 30 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 30 day period, I will be required to obtain a referral from 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 14 days. I hereby consent to the release of my personal health and treatment records to the practitioner named above.

Reasons why you are seeking physical therapy care:

I AM NOT under the care of a licensed healthcare practitioner for the symptoms listed on this form and I wish to seek physical therapy care at this time. (Licensed healthcare practitioner includes a licensed physician, licensed physician assistant practicing under a written agreement, certified registered nurse practitioner practicing under a collaborative agreement, licensed densist or podiatrist for the treatment of a condition that is within their scope of practice.)

I AM under the care of a licensed healthcare practitioner for the symptoms listed on this form and wish to seek physical therapy care at this time. (Licensed healthcare practitioner includes a licensed physician, licensed physician assistant practicing under a written agreement, certified registered nurse practitioner practicing under a collaborative agreement, licensed densist or podiatrist for the treatment of a condition that is within their scope of practice.)

Address

Office Number

Practitioner Name

Fax Number

Patient Signature

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