Direct Access Patient Attestation And Medical Release Form Family Physical Therapy and Wellness, LLC Please enable JavaScript in your browser to complete this form.Patient Full Legal Name *Street address. City, State, Zip Code *Primary Phone Number *Secondary Phone Number:Email *Reason(s) you are seeking Physical Therapy care:CURRENT STATE and ATTESTATION. Please check on below: *I AM NOT under the care of a licensed health practitioner for the symptoms listed on this form and I wish to seek Physical Therapy care at this time. (Licensed health practitioner includes a doctor of medicine, osteopathy, chiropractic, podiatry, dental surgery, licensed nurse practitioner, or licensed physician assistant.) I understand that the current course of Physical Therapy care will last no more than 60 consecutive days, and that additional Physical Therapy services for the symptoms listed on this form shall only be upon the referral and direction of a licensed health practitioner. To receive additional Physical Therapy beyond this 60-day period, I will be required to obtain a referral from a licensed health practitioner.I AM under the care of a licensed health practitioner for the symptoms listed on this form and I wish to seek Physical Therapy care at this time. (Licensed health practitioner includes a doctor of medicine, osteopathy, chiropractic, podiatry, dental surgery, licensed nurse practitioner, or licensed physician assistant.)Practiotioner Name:Practitioner Office Number:Practitioner Street address, City, State, Zip Code:Practitioner Fax Number: I understand that the current course of Physical Therapy care will not last more than 60 consecutive days, and that additional Physical Therapy services for the symptoms listed on this form shall only be upon the referral and direction of a licensed health practitioner. To receive additional Physical Therapy services beyond this 30-day period, I will be required to obtain a referral from the licensed health care practitioner named above. I understand that the practitioner named above will be provided a copy of my initial evaluation and patient history within 14 days. I HEREBY CONSENT TO THE RELEASE OF MY PERSONAL HEALTH AND TREATEMENT RECORDS TO THE PRACTITIONER NAMED ABOVE. Patient Signature (Please Type Your Name): *Date *Submit
