Patient Consent Form

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I, {name-1-prefix} {name-1-first-name} {name-1-last-name}, hereby agree to consent to treatment by an appropriately qualified Physiotherapist for the purpose for providing comprehensive physiotherapy services as may be necessary in support of my illness, injury or condition. I have been given the opportunity to read clinic information prior to treatment. I understand I have the right to decline part or all of the treatment being offered. I understand my right to a second opinion.

Agreement To Pay

I understand that I am liable to pay for:

• Any private treatment or co-payment charges for ACC treatments
• If I fail to attend my appointment or cancel without reasonable notice I may be charged a fee of $20
• If I fail to pay for my appointment at the time of treatment I may be charged an account administration fee
• Any treatment that is declined by ACC or other funder
• The cost of materials such as orthotics, materials, products etc

I understand that if this service requires to engage a Debt Recovery Service to recover my debt, I will be liable for any recovery fees.

Consent To Release Information To A Third Party

I consent to the disclosure of my records to any person/organisation necessary for the effective management of my condition.

I consent to a discharge/update report being sent to my doctor or medical centre.

ACC Declaration

I DECLARE – The information I have given about this claim is true and correct and that I have not withheld any information.

I AUTHORISE – The treatment provider to lodge the claim for me. The collection and release of any information about me to the extent that this is needed to prevent future injuries, determine cover and/or assess my entitlement to compensation, rehabilitation assistance, medical treatment and/or the appropriate level of care and personal attention I should receive. ACC to contact anyone who holds relevant information, including any external agencies or service providers (such as medical practitioners, specialists, New Zealand Police and treatment providers, IRD, WINZ, assessment agencies, employers and witnesses to the accident.

Telehealth Consultation

I hereby agree to consent to a telehealth consultation by an appropriately qualified Physiotherapist for the purpose for providing an assessment and to develop a plan for my injury/condition. I understand the limitations of a telehealth consultation compared to a face to face assessment. I understand I have the right to decline part or all of the treatment being offered. I understand my right to a second opinion.