Informed Consent for Services Provided by DiazPT
DiazPT is a sole proprietorship run by Jana Shaddix Diaz based in Green Cove Springs, Florida, United States of America
Jana Shaddix Diaz is licensed in Florida as a physical therapist. She may provide in-person physical therapy services in Florida as well as Physical Therapy Telehealth services to clients residing in Florida as per the Florida Department of Health. She is recognized internationally as an ACE Certified Health Coach. In this capacity she is able to provide education and guidance in-person and via telecommunications in order to help clients optimize their health and wellness. She is not registered as a physical therapist in the Republic of Panama and, therefore, is unable to provide in-person physical therapy services in that country.
DiazPT services are not suited for emergency care. Services are not intended to be a substitute for professional medical advice, diagnosis or treatment.
Physical therapy involves the use of many different types of physical evaluation and treatment. DiazPT uses a variety of procedures and modalities to help to try and improve your function. As with all forms of medical treatment, there are benefits and risks involved with physical therapy.
Since the physical responses to a specific treatment can vary widely from person to person, it is not always possible to accurately predict your response to a certain therapy modality or procedure. We are not able to guarantee precisely what your reaction to a particular treatment might be, nor can we guarantee that our treatment will help the condition you are seeking treatment for. There is also a risk that your treatment may cause pain or injury, or may aggravate previously existing conditions.
Therapeutic exercises are an integral part of most physical therapy treatment plans. Exercise has inherent physical risks associated with it. If you have any questions regarding the type of exercise you are performing and any specific risks associated with your exercises, your therapist will be glad to answer them.
Telehealth means providing services via electronic communication where the service provider and the client are not at the same physical location. Electronic communication means the use of interactive, secure multimedia equipment that includes, at a minimum, audio and video equipment permitting two-way, real time interactive communication between the service provider and the client. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.Expected benefits of Telehealth include but are not limited to, improved access to services and specialized care, improved program adherence due to convenience, efficiency in care delivery and cost savings. As with any delivery of services, there are potential risks associated with the use of Telehealth. These risks include, but may not be limited to: (in rare cases) information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate decision making by the service provider, delays in service could occur due to deficiencies or failures of the equipment, (in very rare instances) security protocols could fail causing a breach of privacy of personal health information and (in rare cases) a lack of physical examination could lead to an inaccurate plan of care.
Health Coaching is an alliance between the Coach and the Client in a thought-provoking and creative process that inspires the client to maximize their health and wellness. It is designed to facilitate the creation/development of goals and to develop and carry out a strategy/plan for achieving those goals.
Coaching is a comprehensive process that may involve different areas of your life, including work, finances, health, relationships, education and recreation. You agree that deciding how to handle these issues, incorporate coaching principles into those areas and implementing choices is exclusively your responsibility.
You acknowledge that coaching does not involve the diagnosis or treatment of mental disorders as defined by the American Psychiatric Association and that coaching is not to be used as a substitute for counseling, psychotherapy, psychoanalysis, mental health care, substance abuse treatment, or other professional advice by legal, medical or other qualified professionals.
Rights and Responsibilities
You have the right to ask your physical therapist what type of treatment she is planning based on your history, diagnosis, symptoms and testing results. You may also discuss with your therapist what the potential risks and benefits of a specific treatment might be. You have the right to decline any portion of your treatment at any time or during your treatment session.
It is your responsibility to inform DiazPT of pertinent medical conditions, treatments, and medications at your initial appointment and any changes that may occur while you are a client receiving services by DiazPT.
You are responsible for paying the stated fee for services by cash, check, or credit card before or at the time services are provided. If you are prevented from attending a scheduled session and do not cancel the appointment at least 24 hours in advance, you agree to pay the full fee for the service. This practice of being charged for no-shows or late cancellations is standard practice in the field, and takes into account that you are not just paying for services rendered, but reserving a time slot which I cannot offer to someone else on short notice.
You are responsible for providing a suitable form of identity and residence verification upon request (Passport, Driving License, Cedula, etc).
When appointments are scheduled, automatic email reminders of your appointment will be sent to the e-mail you used when scheduling your first appointment. By accepting the terms, you agree to receive these notifications, and understand that email is not a confidential medium for transmitting health information.
DiazPT does not accept payment directly through health insurance plans. However, some insurance companies may reimburse part of your physical therapy expenses. Upon request, We are happy to provide you with a receipt that you can include when filing an insurance claim with your insurance company. DiazPT does not accept responsibility for collecting payment from your insurance company and cannot guarantee that you will be reimbursed or that you will qualify for a reimbursable diagnosis.
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), You have certain rights to privacy regarding your protected health information. DiazPT has a Notice of Privacy Practices containing a more complete description of the uses and disclosure of your health information. You have the right to review the Notice of Privacy Practices prior to signing this consent. It can be found here or a copy can be requested by emailing email@example.com. DiazPT has the right to change its Notice of Privacy Practices from time to time and you may contact us to obtain a current copy of the privacy practices at any time.
If you have any questions, comments or concerns please feel free to email us at firstname.lastname@example.org.
I have read and understand the information contained within this document and would like to proceed with services provided by DiazPT.