Plan end date: (if treatment is ongoing past this date, another plan will be required, no further plan if services cease by this date) Anticipated treatment end date: (if treatment is required beyond the period of this plan) Proposed treatment: (for this plan period) E.g. Standard Consult 15mins -2 Standard Consult 30mins - 12 Total number of services: e.g. 14 Equipment requested: All questions must be answered for this plan to be considered Provider Details Name: Phone: Company/Practice: Email: Address: Signature: Date: Client Declaration and Signature I understand the contents of this plan and agree to: participate in the program, communicate clearly with the provider and medical practitioner, and the release of this plan to the MAIB. Signature: Date: 7 MAIB Authorisation Plan Authorised Yes No Authorisation date: Authorised by: Comments: In the event that benefits are ceased, this authorisation is invalid from the date that the client was notified. Notification to the provider and any unfunded service costs remain the responsibility of the client.
Plan end date: (if treatment is ongoing past this date, another plan will be required, no further plan if services cease by this date) Anticipated treatment end date: (if treatment is required beyond the period of this plan) Proposed treatment: (for this plan period) E.g. Standard Consult 15mins -2 Standard Consult 30mins - 12 Total number of services: e.g. 14 Equipment requested: All questions must be answered for this plan to be considered Provider Details Name: Phone: Company/Practice: Email: Address: Signature: Date: Client Declaration and Signature I understand the contents of this plan and agree to: participate in the program, communicate clearly with the provider and medical practitioner, and the release of this plan to the MAIB. Signature: Date: 7 MAIB Authorisation Plan Authorised Yes No Authorisation date: Authorised by: Comments: In the event that benefits are ceased, this authorisation is invalid from the date that the client was notified. Notification to the provider and any unfunded service costs remain the responsibility of the client.
Physiotherapy-Management-Plan.docx