PURPOSE: This rule provides information concerning the disclosure of a physician’s pecuniary interest in a physical therapy or rehab ilita tion service as directed by sec tion 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.