Ultimate Physical Therapy Patient Information Form (Page 4 of 5) in pdf

Ultimate Physical Therapy Patient Information Form Page 4

ULTIMATE PHYSICAL THERAPY, PLLC

On July 27th, 2006, Congress passed legislation that allows patients in New York who need

physical therapy to go directly to their physical therapist without a referral from a physician.

This law went into effect on November 24th, 2006. It does not apply to patients who are

covered under Workers Compensation, No Fault, and Medicare or to patients who have

pending liability cases.

In accordance with the “Direct Access” Law, please read and sign at the bottom.

I understand that I am eligible to have physical therapy although I do not have a

referral from a physician, dentist, podiatrist, or nurse practitioner. 

I understand that I am eligible to receive either 10 sessions of physical therapy or to be

seen for thirty calendar days, whichever comes first, without a referral.

I understand that I must obtain a referral from a physician after I eitherreceive 10

sessions of physical therapy or the time limit expires, whichever occurs first. 

I understand that my insurance company may not cover my sessions without a

prescription and that treatment may be a covered expense if I obtain such referral. In

the event that my insurance denies my physical therapy, I understand that I am fully

responsible for any and all uncovered sessions. 

I attest that my condition is not related to a No-Fault Injury. 

I attest that my condition is not related to a Workers Compensation injury. 

I attest that there is no pending liability case related to my condition. 

I attest that I am not covered under Medicare. 

I acknowledge that I have read and understand the above statements.

Signature:_____________________________________________Date______________________

Ultimate Physical Therapy Patient Information Form Page 4