OCCUPATIONAL THERAPY

Occupational Therapy Services & Scope of Care

Occupational therapy services at Banyan & Nomad may include evaluation, assessment, treatment planning,  therapeutic activities and exercises, functional training, education, development of home programs, and other  interventions within the professional scope of occupational therapy.

Depending on your individual needs and goals, occupational therapy may address areas such as:

• mobility, balance, coordination, and functional movement;

• strength, endurance, flexibility, and range of motion as they relate to daily function;

• posture, body mechanics, and movement strategies;

• activities of daily living and everyday functional tasks;

• sensory, proprioceptive, and neuromuscular function;

• adaptive strategies and use of appropriate equipment;

• development or restoration of skills needed for greater safety, independence, and participation in daily life; and • education and recommendations related to your individualized occupational therapy plan of care. Your occupational therapist will determine appropriate interventions based on professional assessment, your  individual needs and goals, relevant health information, and the therapist’s professional scope of practice.

Occupational therapy does not replace medical care that falls outside the occupational therapist’s professional  scope. When appropriate, you may be advised to consult or follow up with a physician or another qualified healthcare  professional.

Consent to Evaluation and Treatment

You voluntarily consent to occupational therapy evaluation and treatment provided by a licensed occupational  therapist at Banyan & Nomad.

Your occupational therapist will discuss the nature and purpose of recommended services with you and, when  appropriate, explain relevant treatment options, anticipated benefits, material risks or discomforts, and reasonable  alternatives within the therapist’s scope of practice.

You have the right to ask questions about your care at any time.

You may decline a particular activity, technique, or intervention or withdraw your consent to treatment. If you have  concerns about any aspect of your care, please discuss them with your occupational therapist so that appropriate  alternatives or modifications can be considered when available.

No particular outcome or result from occupational therapy can be guaranteed.

Hands-On Assessment, Guidance & Treatment

Occupational therapy may involve appropriate physical contact when clinically relevant to evaluation or treatment.  This may include hands-on assessment, positioning, movement guidance, assistance with functional activities,  facilitation of movement, or other therapeutic techniques within the occupational therapist’s scope of practice.

Your comfort and personal boundaries are important.

Please tell your occupational therapist if you are uncomfortable with a particular form of physical contact or would like  an explanation before a hands-on technique is used. You may ask your therapist to stop a technique or activity at any  time.

Accuracy of Health & Medical Information

I certify that the health and medical information I provide is complete and accurate to the best of my knowledge.

I understand that accurate information is important for appropriate evaluation, treatment planning, and safe delivery  of occupational therapy services.

I agree to disclose relevant medical conditions, diagnoses, injuries, surgeries, medications, allergies, physical or  cognitive limitations, pregnancy, recent procedures, and other health information that may affect my care.

I understand that it is my responsibility to inform my occupational therapist of significant changes in my health,  medications, symptoms, functional abilities, or medical condition that occur after completing this form.

Potential Benefits and Risks of Occupational Therapy

Occupational therapy is individualized, and outcomes vary from person to person. Potential benefits may include  improved functional ability, mobility, balance, coordination, strength, endurance, body awareness, confidence with  daily activities, and greater independence or participation in meaningful activities.

Occupational therapy may also involve physical exertion or activities that produce temporary fatigue, muscle  soreness, discomfort, or other physical responses.

Depending on the nature of your condition and treatment, potential risks may include:

1. Musculoskeletal discomfort or injury: temporary soreness, muscle strain, joint discomfort, aggravation of an  existing condition, loss of balance, falls, or other physical injury.

2. Responses to activity or exertion: fatigue, dizziness, shortness of breath, changes in heart rate or blood pressure, or  other symptoms associated with physical activity.

3. Functional or balance activities: activities involving walking, transfers, reaching, changes of position, balance,  coordination, or other functional tasks may involve a risk of losing balance or falling.

4. Equipment: use of therapeutic or exercise equipment may involve additional risks if equipment is used improperly  or if unexpected physical responses occur.

5. Individual response: symptoms may temporarily increase or change in response to treatment, and individual  outcomes cannot be predicted or guaranteed.

Please communicate pain, dizziness, unusual shortness of breath, significant discomfort, unexpected symptoms, or  concerns to your occupational therapist promptly. Your therapist may modify or discontinue an activity when clinically  appropriate.

Equipment Use & Safety

Occupational therapy may involve therapeutic, adaptive, mobility, balance, exercise, or other equipment appropriate  to your treatment plan.

Please use equipment only as instructed or directed by your occupational therapist. Do not independently adjust,  move, mount, dismount, or use equipment unless you have received appropriate instruction or permission.

If equipment appears damaged, unstable, improperly adjusted, or unsafe, stop using it and notify your occupational  therapist immediately.

Patient Responsibilities

1. Provide complete and accurate health and medical information to the best of your knowledge.

2. Inform your occupational therapist of relevant changes in your health, medications, symptoms, injuries, or  functional abilities.

3. Follow reasonable safety instructions and communicate when an activity causes pain, unusual discomfort,  dizziness, or other concerning symptoms.

4. Ask questions whenever you do not understand an instruction, recommendation, treatment activity, or aspect of  your plan of care.

5. Use therapeutic equipment only as directed.

6. Participate in your care and home recommendations to the extent that you are able and comfortable doing so.

Privacy & Confidentiality

Banyan & Nomad and its authorized healthcare personnel will collect and maintain personal and health information  necessary to provide and document occupational therapy services.

Your personal and health information will be treated as confidential and maintained in accordance with applicable  privacy, professional, recordkeeping, and healthcare laws and requirements.

Information may be used for purposes related to your care, documentation, administration, billing, payment, and  other legally permitted healthcare operations, as applicable.

Your information will not be disclosed to third parties except with your authorization or as otherwise permitted or  required by applicable law.

When appropriate for coordination of your care, you may be asked to authorize communication with your physician,  referring provider, physical therapist, or another healthcare professional.

Where a separate authorization for release of information is legally required, you will be asked to complete that  authorization.

Communication With Other Healthcare Professionals

Coordination with another healthcare professional may sometimes be helpful to your occupational therapy care.

With your authorization, Banyan & Nomad may communicate relevant information to or obtain relevant information  from your physician, referring provider, physical therapist, or other healthcare professional involved in your care.

Only information reasonably relevant to the authorized purpose should be communicated. You may withdraw an authorization for future disclosures in accordance with applicable law.

Communicable Illness

Please do not attend an in-person appointment if you are experiencing symptoms of a potentially contagious illness  that could reasonably place others at risk.

If you are unsure whether it is appropriate to attend, please contact the practice and, when appropriate, seek  guidance from your healthcare provider.

Banyan & Nomad may ask a patient who appears to be potentially contagious to reschedule an in-person appointment  when reasonably necessary to protect patients, practitioners, and others in the practice.

Telehealth or Remote Occupational Therapy

If occupational therapy services are provided remotely, additional considerations apply because your occupational  therapist is not physically present and may have limited ability to assess your environment, provide physical  assistance, or respond directly to an emergency.

Before a remote session, please ensure that you have a reasonably safe environment, adequate space for the  activities being performed, and any equipment requested by your therapist.

Follow your therapist’s instructions and immediately report pain, dizziness, unusual symptoms, environmental  hazards, or other concerns.

Your therapist may determine that a particular evaluation, intervention, or activity is not appropriate for remote  delivery and may recommend an in-person appointment or referral to another healthcare professional.

Referrals and Coordination of Care

Occupational therapy services will be provided in accordance with applicable New York requirements concerning  professional scope of practice and referrals.

When a referral or prescription from an authorized healthcare provider is required for continued treatment, you are  responsible for obtaining the required referral or cooperating with the practice in obtaining appropriate  documentation.

Treatment Without a Referral, When Legally Applicable

If occupational therapy treatment is provided without a physician or nurse practitioner referral under circumstances  permitted by New York law, you will receive any additional notice or acknowledgment required by applicable law,  including information concerning the possibility that services provided without a referral may not be covered by your  health plan or insurer.

Any required direct-access acknowledgment should be completed separately and retained as part of your patient  record.

Appointment, Cancellation & Payment Policy

Occupational therapy appointments are by appointment only.

Payment, copayment, coinsurance, deductible amounts, or other patient financial responsibility is due according to  the payment arrangements applicable to your services.

If you need to cancel or reschedule an appointment, please provide at least 24 hours’ notice. Appointments cancelled  or changed with less than 24 hours’ notice may be subject to the practice’s cancellation fee, except where prohibited  by law, contract, or applicable payer requirements.

If you arrive more than 25 minutes late, there may not be sufficient time to provide the scheduled service safely and  appropriately, and your appointment may need to be rescheduled.

Where prepaid private-pay services are offered, applicable terms will be disclosed before purchase.

Professional Relationship and Emergencies

Occupational therapy services at Banyan & Nomad are provided within the professional scope of occupational  therapy.

Occupational therapy appointments are not emergency medical services.

If you believe you are experiencing a medical emergency, call 911 or seek appropriate emergency medical care rather  than contacting or traveling to the practice for an occupational therapy appointment.

General Legal Provisions

Governing Law: This Consent shall be governed by and interpreted in accordance with the laws of the State of New  York, to the extent applicable.

Severability: If any provision of this Consent is determined to be invalid or unenforceable, the remaining provisions  will remain in effect to the extent permitted by law.