Patient Forms & Documents

PATIENT NAME: ___________________________________________     DATE: _______________

1. Authorization for Physical Therapy Treatment

I, the undersigned patient (or legal guardian/authorized representative), hereby authorize NeuroMotion Home PT, LLC and its licensed physical therapist(s), including but not limited to Dr. Sarah Khalil, DPT, NCS, to administer physical therapy treatment to me (or the patient named above). I understand that this authorization includes evaluation, therapeutic exercise, manual therapy, neuromuscular reeducation, functional mobility training, patient education, and all other physical therapy interventions deemed appropriate by the treating therapist.

2. Nature and Purpose of Treatment

Physical therapy is a healthcare profession that uses evidence-based methods to improve, restore, and maintain physical function. Treatments may include therapeutic exercise, manual therapy techniques, balance training, neuromuscular re-education, gait training, functional mobility activities, and home program instruction. The goals, procedures, and expected outcomes of treatment will be discussed with me by my therapist before initiation of care.

3. Home Visit — Assumption of Risk & Home Environment

I understand that physical therapy sessions will be conducted in my home environment. I acknowledge that the home setting differs from a clinical facility and that I accept certain inherent risks associated with receiving care in my home. These include, but are not limited to: unexpected falls, tripping hazards specific to my home environment, household pets, weather-related delays, and limited access to emergency equipment that would be available in a clinical setting.

I agree to make reasonable efforts to prepare a safe space for therapy, including but not limited to: removing obvious trip hazards, containing pets during the session, ensuring adequate lighting, and informing the therapist of any known hazards. I understand that NeuroMotion Home PT will conduct a home safety assessment at or prior to the initial evaluation.

4. Risks of Physical Therapy

Physical therapy is generally safe. However, I understand that like any healthcare intervention, there are potential risks, including but not limited to: temporary soreness or discomfort, muscle fatigue, falls during therapeutic exercise (despite therapist precautions), skin irritation from equipment, and in rare cases, exacerbation of symptoms. I understand that I may withdraw consent and discontinue treatment at any time.

5. HIPAA Notice of Privacy Practices

I acknowledge that I have received (or have been offered) a copy of NeuroMotion Home PT's Notice of Privacy Practices. I understand that my protected health information (PHI) will be used and disclosed in accordance with applicable federal and state law, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA). My information may be shared with: (a) other healthcare providers involved in my care, (b) insurance companies for billing and payment purposes, (c) healthcare operations of NeuroMotion Home PT. Any other disclosure of my PHI requires my written authorization, which I have the right to revoke at any time, subject to the limitations set forth in the Notice of Privacy Practices.

6. Financial Responsibility

I understand and agree that I am financially responsible for any charges not covered by my insurance, including co-payments, deductibles, and non-covered services. I authorize NeuroMotion Home PT to bill my insurance on my behalf and to receive payments directly from my insurer.

7. Photography & Video

I ☐ DO / ☐ DO NOT consent to photographs or video recordings being taken for the purpose of documenting my progress. I understand that such recordings are part of my medical record and subject to HIPAA protections.

8. Acknowledgment

By signing below, I confirm that I have read (or had read to me) this consent form, that I have had the opportunity to ask questions, and that I voluntarily consent to receive physical therapy services from NeuroMotion Home PT in my home environment.

This authorization is made pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR §164.508.

Releasing Party (Source of Records)

Receiving Party

Specific Records Authorized for Release

Expiration

This authorization expires one (1) year from the date of signature, or upon the completion of the purpose stated above, whichever occurs first.

Right to Revoke

I understand that I have the right to revoke this authorization at any time by providing written notice to NeuroMotion Home PT. Revocation will not apply to actions already taken in reliance on this authorization. I understand that the information released pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by HIPAA.

NeuroMotion Home PT will conduct a home safety assessment at or prior to your initial evaluation. The purpose of this assessment is to identify hazards in your home that may increase fall risk or impede therapy delivery.

Assessment Areas

The assessment will evaluate, as applicable: entry and exit points, floor surfaces (rugs, transitions, thresholds), stairways and handrails, bathroom safety (grab bars, tub/shower access, toilet height), bedroom access, lighting, assistive equipment placement, and general fall hazards.

Patient Acknowledgment

I understand that the home safety assessment is advisory in nature. I acknowledge that I am not required to make any modifications to my home, but I understand that identified hazards represent genuine safety risks. I agree to discuss recommendations with Dr. Khalil and to make reasonable efforts to address hazards that pose imminent fall or injury risk during therapy sessions.

I acknowledge that NeuroMotion Home PT cannot be held liable for falls or injuries that occur in areas of my home that were not disclosed, were inaccessible during assessment, or where recommended safety modifications were not implemented.

Pets & Access

I agree to contain or secure household pets during all therapy sessions to prevent interference with treatment and to ensure both patient and therapist safety. I will ensure that the therapy area is clear of tripping hazards prior to each visit.

I hereby authorize NeuroMotion Home PT, LLC to submit claims to my insurance carrier(s) and to receive direct payment from such carriers for services rendered. I authorize the release of any medical information necessary to process these claims.

I understand that I am financially responsible for any balance remaining after insurance payment, including co-pays, deductibles, co-insurance, and non-covered services. I agree to pay such balances within 30 days of receiving my statement.

What is Telehealth?

Telehealth involves the use of electronic communications to enable healthcare providers to connect with patients using interactive audio and video technology. NeuroMotion Home PT uses HIPAA-compliant video platforms for telehealth follow-up sessions.

Benefits and Risks of Telehealth

Benefits: Access to care without travel, convenience, continuity between home visits, lower time burden, and access for international patients. Potential risks: Technology failures, limitations of visual assessment (inability to perform hands-on techniques), privacy concerns if sessions are conducted in non-private settings, and delays in emergency response if needed.

Patient Responsibilities

1. I will participate in telehealth sessions from a private, reasonably quiet location.
2. I will have a responsible adult present if I have significant safety concerns or fall risk.
3. I will not record telehealth sessions without prior written consent of NeuroMotion Home PT.
4. I understand I may request an in-person home visit at any time if telehealth is not meeting my needs.

Jurisdiction

I understand that Dr. Khalil is licensed to practice physical therapy in New Hampshire and Massachusetts. I confirm that I will be physically located within these states during all telehealth sessions, unless Dr. Khalil has confirmed licensure reciprocity for my state.

Consent

I voluntarily consent to receive telehealth services from NeuroMotion Home PT. I understand I may withdraw this consent at any time without affecting my right to receive in-person care.