Forms — Stable Body Physical Therapy

Equine Referral Form

All equine athletes are REQUIRED to have a referral from the overseeing veterinarian on file.

This form is for veterinarian offices only

Veterinarian Referral

Referring Veterinary Clinic

Office Contact:

(###)

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Referring Veterinarian Name

First Name

Last Name

Referring Veterinarian Email

Owner Name

First Name

Last Name

Owner Contact:

(###)

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Horse Name:

Referral For:

Medical History:

add anything of note including current medications

I certify that I am the overseeing Doctor of Veterinary Medicine or a representative of the DVM on behalf of the veterinarian.

I agree

Patient Forms

Before your evaluation, please fill these 3 forms out and submit them.

Equine Owners only need to sign the Release of Liability.

Consent to Treat

I understand that Stable Body Physical Therapy will maintain my privacy to the highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. Photographs taken during initial evaluation, progress evaluation and discharge summary will be used for postural comparison purposes and as educational tools. By signing below I consent to the use of these photographs in a professional manner. I do hereby agree and give my consent for Stable Body Physical Therapy to furnish care and treatment that is considered necessary and proper in the diagnosing or treating of my physical condition. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time. I hereby certify that all the above information is true to the best of my knowledge.

Patient Name/Signature

First Name

Last Name

Parent/Guardian Signature

First Name

Last Name

Date

YYYY

By checking this box I agree that all the above information is true and I agree to the Terms and Conditions of the Consent to Treat form.

I AGREE

HIPAA Compliance

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPAA” provides penalties for covered entities that misuse personal health information. As required by “HIPAA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your information. We may use and disclosed your medical records only for each of the following purposes: treatment, payment and health care operations. Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical examination. Payment means such activities as obtained reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment. Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review. We may also create and distribute de-identified health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer: The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations. The right to inspect and copy your protected health information. The right to amend your protected health information. The right to receive an accounting of disclosures of protected health information. The right to obtain a paper copy of this notice from us upon request. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. This notice is effective as of below date and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

Patient Name/Signature

First Name

Last Name

Parent/Guardian Signature

First Name

Last Name

By checking this box I agree that all the above information is true and I agree to the Terms and Conditions of the HIPAA Compliance Form.

I agree

Date

YYYY

Signature

Release of Liability

Horse owner/Horse Guardian/Patientl willfully agrees to submit consent to allow Stable Body Physical Therapy, LLC permission to perform human and/or equine physical therapy assessment + treatment today and on all future scheduled dates. Horse owner/Horse Guardian/Patient has been notified that equine physical therapy services are not substitutes for veterinary care/medicine and that there is a referral from DVM in place that is up-to-date on current health. Horse owner/Guardian/Patient is aware that Stable Body Physical Therapy LLC has a compassion and understanding for horses and treats them and their owners with trust, understanding and respect. Horse owner/guardian understands they have the right to express any discomfort in the treatment or terminate treatment at any time. Horse owner/guardian has been notified that they have the option of calling or emailing Stable Body Physical Therapy, LLC with any concerns before or after a treatment. Horse owner/Guardian/Patient agrees to release Stable Body Physical Therapy, LLC from any loss, damage, liability or injury arising out of, or resulting from, participation in, Equine and Equestrian Physical Therapy Treatments, including any negligent acts or omissions. By signing this release form, I do hereby agree to indemnify, hold harmless, and defend Stable Body Physical Therapy from any loss, damage, liability, or injury, however caused, resulting directly or indirectly from her participation, or from acts or omission. I acknowledge that activities with and around horses involve inherent risks of physical injury to participants, horses, and others which the horse owner/guardian understands and expressly assumes.

Sign Below:

First Name

Last Name