New Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations
The Healthcare Insurance Portability and Accountability act of 1996 (“HIPPA”) is a federal program, which requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally are kept confidential. This act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPPA” provides penalties for covered entities that misuse personal health information.
We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.
As required by “HIPPA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.
We may use and disclose your medical records only for each of the following purposes: treatment, payment, health care operations.
The purpose of outpatient orthopedic Physical Therapy is to diagnose and treat conditions that affect musculoskeletal system and assist in the treatment and care of some neurological and cardiovascular diseases. I will utilize manual therapy skills including, but not limited to joint and soft tissue mobilization, muscle energy techniques and may employ instrument or modality assistance (IE: dry needling, IASTM).
Pilates-based exercises or programs may be prescribed for home practice or performed in clinic as another form of intervention as we work towards your plan of care/goals. All procedures will be thoroughly explained to you before you are asked to participate in them.
Response to intervention varies from person to person; hence, it is not possible to accurately predict your response to a specific modality, procedure, or exercise protocol. I cannot guarantee what your reaction will be to a specific treatment, nor can I guarantee that the treatment will resolve the condition that you are seeking treatment for. Furthermore, there is a possibility that the Pilates-based Physical Therapy treatment may result in aggravation of existing symptoms and may cause pain or injury. It is very important to communicate with me throughout your treatment.
It is your right to decline any part of your treatment at any time before or during treatment, should you feel any discomfort or pain or have other unresolved concerns. It is your right to ask me about the treatment planned based on your individual history, physical therapy diagnosis, symptoms, and examination results. Consequently, it is your right to discuss the potential risks and benefits involved in your treatment.
I have read this information and understand the risks involved in physical therapy/pilates and agree to fully cooperate, participate in all agreed upon physical therapy procedures/exercise prescription, and comply with the established plan of care. I understand that Steel and Air Pilates-based Physical Therapy will not file insurance claims for payment and that payment is due at the time of my session.
Dry Needling (DN) involves inserting a tiny monofilament needle in a muscle or muscles in order to create change in musculature. This can help resolve pain and muscle tension, and will promote healing. This is not traditional Chinese Acupuncture, but is instead a medical treatment that relies on a medical diagnosis to be effective. Your physical therapist has met requirements for competency Dry Needling and is certified to practice this modality. DN is a valuable and effective treatment for pain and muscular dysfunction, but like any treatment, there are possible complications. While complications are rare, they are real and must be considered prior to giving consent for treatment.
Risks: Although uncommon, there can be symptoms/risks related to DN. If you have any questions, feel free to consult with your therapist. This information will be reviewed with you prior to treatment.
Common Symptoms
Needle Insertion Pain
Muscle Soreness or Fatigue
Bruising
Uncommon Symptoms
Aggravation of Symptoms
Feeling Faint or Dizzy
Headache
Rare/Very Rare
Infection
Pneumothorax
Vasovagal Response/Fainting
GI Issue (nausea, vomiting)
Numbness/tingling
Emotional Response
Patient’s Consent: I understand that no guarantee or assurance has been made as to the results of this procedure and that it may not cure my condition. We have reviewed the possible side effects and my questions have been answered. Multiple treatment sessions may be required/needed, thus this consent will cover this and all future DN treatment.
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