I hereby give permission for MANUAL FIZIO l COLLABORATIVE PHYSICAL MEDICINE employees and professional staff to evaluate and, if appropriate, render subsequent treatment in accordance with the plan of care authorized by my physician (if applicable) or by my personal authorization. I understand that I will be given all available pertinent information prior to the treatment being rendered. I will be given the opportunity to ask questions and have them answered to my satisfaction. I understand that I may decline treatment at any time.
That I understand as part of my healthcare, MANUAL FIZIO l COLLABORATIVE PHYSICAL MEDICINE originate and maintain papers as records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as:
- a basis for planning my care and treatment;
- a mean of communication among other health professionals who contribute to my care; and,
- a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.
That I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:
- the right to review the notices prior signing this consent;
- the right to request restrictions as to how my health information may be used or disclosed to carry out treatment.
That I understand that MANUAL FIZIO l COLLABORATIVE PHYSICAL MEDICINE is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me.
I further understand that MANUAL FIZIO l COLLABORATIVE PHYSICAL MEDICINE is a modern Manual Physical Therapy clinic, specializes in pain science education, repeated motion and reinforcement which means that the treatment of their choice is based on different techniques that they acquired in training in Manual Therapy Approach.
I fully understand and by submiting this form would mean I fully accept the terms of this consent.