PURPOSE: This rule provides information concerning the disclosure of a physician’s pecuniary interest in a physical therapy or rehabilitation service as directed by section 334.100.2(21), RSMo.

1. (1) Pursuant to the authority granted in section 334.100.2(21), RSMo, physicians who have a pecuniary interest in physical therapy or rehabilitation service facilities must disclose that interest to patients who are prescribed either physical therapy or rehabilitation services using the following form: Missouri state law, 334.100.2(21), RSMo, requires a physician notify the patient or guardian that the physician has a pecuniary (financial) interest in the physical therapy facility in which prescribed treatment is provided, and that physical therapy or rehabilitation services are available to the patient on a competitive basis from other facilities.

Therefore, I understand that Dr.__________________________ has a financial interest in ________________________facility.

Further, I understand that I have the right to choose any other physical therapy or rehabilitation services which may be more convenient or competitive.

_________________________ Patient/Guardian Signature

_________________________

Date

This should be retained in the patient’s permanent record.

AUTHORITY: sections 334.100.2(21), RSMo Supp. 1990 and 334.125, RSMo 1986.* This rule originally filed as 4 CSR 150-5.030. Original rule filed April 4, 1990, effective Nov. 30, 1990. Moved to 20 CSR 2150-5.030, effective Aug. 28, 2006. *Original authority: 334.100.2(21), RSMo 1939, amended 1945, 1959, 1963, 1974, 1976, 1979, 1981, 1983, 1984, 1986, 1987, 1989, 1990 and 334.125, RSMo 1959.