California

You are receiving direct physical therapy treatment services from an individual who is a physical therapist licensed by the Physical Therapy Board of California.

Under California law, you may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits, whichever occurs first, after which time a physical therapist may continue providing you with physical therapy treatment services only after receiving, from a person holding a physician and surgeon’s certificate issued by the Medical Board of California or by the Osteopathic Medical Board of California, or from a person holding a certificate to practice podiatric medicine from the California Board of Podiatric Medicine and acting within his or her scope of practice, a dated signature on the physical therapist’s plan of care indicating approval of the physical therapist’s plan of care and that an in-person patient examination and evaluation was conducted by the physician and surgeon or podiatrist.

Georgia

The State of Georgia Physical Therapy Practice Act allows physical therapists to evaluate patients without a referral from a medical doctor. This type of visit is known as “self-referral.” Your physical therapist will perform an evaluation and develop a plan of care specific to your complaints. Direct access by self-referral in Georgia allows for treatment for 21 days or 8 visits from the initiation of a physical therapy plan of care. If your symptoms have not resolved by that time, you will be referred to obtain a referral to continue treatment. Additionally, if your signs and symptoms are not appropriate for physical therapy care, your physical therapist will refer you directly to the appropriate medical professional for further assessment.

By signing below, you understand:

• Your physical therapist will determine a physical therapy diagnosis. This is not a medical diagnosis by a physician or based on radiologic imaging.
• Although self-referral is legally permitted, physical therapy may not be covered by the patient’s health care plan or insurer without such a referral, and such treatment may be a covered expense if rendered under a referral. Patients are advised to consult their insurance provider to understand the extent of coverage and potential limitations.
• You cannot participate in dry needling treatment intervention without consulting an appropriate medical professional.

Kansas

The state of Kansas allows patients to access physical therapy services directly without a referral from a physician, podiatrist, physician assistant, advanced nurse practice nurse, chiropractor, dentist, or optometrist.

The diagnosis provided by your physical therapist is a physical therapy diagnosis. A physical therapy diagnosis is not a medical diagnosis by a physician.

If you do not make measurable or functional progress toward documented treatment goals within 10 visits or 15 business days from the initial evaluation, you will be referred to an appropriate licensed healthcare provider for further evaluation and continued physical therapy services, if warranted.

By signing below, I attest that I have read and understand the disclosure for self-referral to physical therapy.

New York

Under New York State law, individuals seeking physical therapy services have the right to directly access and receive evaluations and treatments from a licensed physical therapist without obtaining a referral or prescription from a physician or other healthcare provider. Physical therapy treatment may be provided for up to ten visits or 30 days, whichever comes first, without a referral or prescription. If further treatment is required beyond this timeframe, a referral or prescription from an appropriate healthcare provider will be necessary.

While direct access allows patients to take a more active role in managing their healthcare, it is important to note that there are certain limitations and conditions to be aware of. The following guidelines and restrictions apply to the provision of physical therapy services under direct access in New York:

• Initial Evaluation: Only a licensed physical therapist, with at least 3 years’ experience, may evaluate a patient without a referral or prescription. During this evaluation, the physical therapist will determine the appropriateness and scope of treatment and may recommend additional medical consultation if necessary.
• Insurance Coverage: Although direct access is legally permitted, physical therapy may not be covered by the patient’s health care plan or insurer without such a referral, and that such treatment may be a covered expense if rendered pursuant to a referral.

Patients are advised to consult their insurance provider to understand the extent of coverage and potential limitations.

Rhode Island

The state of Rhode Island allows direct access to physical therapy services for up to 90 days from a physical therapist with more than 1 year of experience. If treatment beyond 90 days is necessary, you will be referred to an appropriate healthcare practitioner. Additionally, we are required to disclose the scope and limitations of physical therapy in accordance with the “American Physical Therapy Association, Standards of Practice for Physical Therapy and Code of Ethics.”

Scope of Practice:

• Physical therapy is a healthcare profession that focuses on promoting, restoring, and maintaining physical function and mobility. Physical Therapists are trained and licensed to evaluate, diagnose, and treat a wide range of musculoskeletal, neurological, and cardiopulmonary conditions that may affect your physical well-being.
• During your physical therapy sessions, all components of evidence-based practice along with various techniques and interventions will be used to help alleviate pain, improve mobility, increase strength and flexibility, and enhance your overall physical performance. These may include manual therapy, therapeutic exercises, modalities (such as heat or electrical stimulation), education, and patient-specific treatment plans.

Limitations of Practice:

• While physical therapy can be highly effective in many cases, it is important to recognize that there are certain limitations to what it can achieve. Physical therapy may not be able to completely cure certain chronic or degenerative conditions, and it may not provide immediate or permanent relief in all cases.
• It is also essential to understand that physical therapy is not a substitute for medical diagnoses or treatment provided by other healthcare professionals. If during the course of your treatment, issues are identified that fall outside the scope of physical therapy practice, you will be referred to an appropriate specialist or healthcare provider to ensure you receive the most comprehensive care.

I understand that I am seeking physical therapy services via direct access and understand the scope and limitations of physical therapy. By signing below, I consent to direct access physical therapy care.

Tennessee

In the state of Tennessee, a physical therapist can conduct an initial patient visit without a referral. To continue to treat a patient without a referral, is also known as, “direct access”. For continued treatment beyond the initial visit, the physical therapist is obligated to the following requirements:

• Notify the patient’s healthcare practitioner.
• No longer provide additional treatment if the treating physical therapist determines that no progress has been made within thirty (30) days. The physical therapist will then be required to send a referral to the patient’s healthcare practitioner.
• The physical therapist will not be able to continue services beyond ninety (90) days without consulting the patient’s appropriate healthcare practitioner.

By signing below, I acknowledge that I understand the information above, and that I am seeking “direct access services” and do not have a licensed Doctor of Medicine, chiropractor, dentist, podiatrist, or Doctor of Osteopathic Medicine for the treating injury.

Texas

Physical Therapy Treatment without Referral Disclosure

Please read carefully and acknowledge below:

• I understand that physical therapy treatment without a referral will be based on the physical therapist’s examination and evaluation of my current condition which may result in the identification of movement and mobility dysfunction.
• I understand that the physical therapist will not diagnose an illness or disease, and that physical therapy is not a substitute for a medical diagnosis.
• I understand that if a medical diagnosis has already been established by a qualified healthcare practitioner, the physical therapist will take it into consideration during the evaluation process.
• I understand that the physical therapy plan of care developed by the physical therapist may not be based on radiological imaging.
• I understand that if images have previously been obtained, the physical therapist may use the information as part of the evaluation process.
• I understand that if the physical therapist identifies a need for radiological imaging, the physical therapist may recommend that radiological imaging be obtained.
• I understand that my health insurance may not cover physical therapy services if provided without a referral from a qualified healthcare practitioner.

I acknowledge that I have received the above disclosure.