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Personal Information
Informed Consent Form
You have consulted with Ipath Therapy, and have decided to receive therapy services. It is important that you, the client, read this consent form carefully and obtain answers to any questions that you may have.
Physical and Occupational Therapy: Physical therapy involves several methods of evaluation and treatment. We use a variety of procedures and treatments to help us try and improve your physical and psychosocial function. As with all forms of medical treatment, there are benefits and risks involved. Patient responses to a specific form of treatment can vary widely from patient to patient, and it is not always possible to predict responses to a given form of treatment. There is a risk that your treatment may result in pain, injury, or aggravation of a previous condition.
Speech Therapy: Speech involves several methods of evaluation and treatment. We use a variety of procedures and treatments to help us try and improve your function. As with all forms of medical treatment, there are benefits and risks involved. Patient responses to a specific form of treatment can vary widely from patient to patient, and it is not always possible to predict responses to a given form of treatment. There is a risk that your treatment may result in pain, injury, or aggravation of a previous condition.
You have the right to inquire as to the form of treatment based upon your history, diagnosis, and symptoms.
You may discuss with your provider the potential risks and benefits of a specific treatment and possible alternative treatment.
You have the right to decline treatment at any time or during your treatment sessions.
Your therapist will answer questions you may have regarding a given course of treatment, type of exercise or treatment method, associated risks, and possible alternatives.
This consent form is based upon your informed decision to participate in the proposed treatment plan for therapy services. The therapist identified on this form has discussed with me in words that I can understand, my diagnosis, conditions, reasons for and benefits of the plan of care, the reasonable likelihood of success, the possible material risks of not following the plan of care, the possible risks associated with the plan of care, and possible alternatives and risks associated with those alternatives. The therapist identified in this form and I have discussed my goals of recovery and potential problems that might arise during treatment. I have decided not to participate in alternative treatments at this time. I understand there are risks associated with therapy as described above. I am giving this consent with the understanding that any treatment or services involve some risks and hazards, and that no guarantees have been made to me.
I acknowledge that services may be provided to me by another therapist other than identified on this form.
I HEREBY CERTIFY THAT I HAVE READ THIS FORM (OR HAVE HAD IT READ TO ME) AND FULLY UNDERSTAND THE ABOVE CONSENT. I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS, AND ALL OF MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION. I DO NOT DESIRE ANY FURTHER EXPLANATION AND UNDERSTAND AND ACKNOWLEDGE THAT COMPLICATIONS CAN RESULT.
Release of Information
I hereby authorize the release of any information by telephone, email/fax, or in writing, including reports of diagnosis, treatment prognosis, recommendation, as well as any other data pertinent to my treatment, by Ipath Therapy DBA to the physician who referred me for therapy, and any names listed below. I also authorize the release of any information by telephone or in writing for utilization and quality review purposes.
Notice of Privacy Practices
I acknowledge receipt of the Notice of Privacy Practices from Ipath Therapy DBA. I understand that the Notice of Privacy Practices provides information about how Ipath Therapy DBA may use and disclose my protected health information. I have reviewed it and understand that the Notice of Privacy Practices is subject to change. If the Notice is changed, I may request a revised copy.
Assignment of Insurance
Benefits I hereby authorize that the payment of authorized benefits is made directly to Ipath Therapy DBA of any services that are reimbursable by Medicare or other insurance if applicable.
Consent for Treatment
I hereby consent to such treatment procedures and patient care which, in the judgment of my therapist and/or physician, may be considered necessary or advisable while I am a patient of Ipath Therapy DBA.
Guarantee of Account
I hereby guarantee payment for any and all services rendered to me which are not covered or allowable by my insurance, together with collection costs, including reasonable attorney fees. I also understand that all bills are due and payable upon presentation. I understand that the client’s responsibility portion of my bill shall be due and payable at the time of services. I understand that I am personally responsible for full payment of all charges including insurance denials, deductibles, and copayment fees. I understand that I will be provided with an invoice for services not covered by my insurance in which I can submit to my own insurance for reimbursement in consideration of services rendered to me by Ipath Therapy DBA