I ACKNOWLEDGE THAT I HAVE BEEN ADVISED BY MY PHYSICAL THERAPIST THAT HE HAS A FINANCIAL OR OWNERSHIP INTEREST IN THE FACILITY OR ENTITY TO WHICH HE HAS REFERRED ME, AND THAT HE HAS ADVISED ME THAT I AM FREE TO CHOOSE ANOTHER FACILITY OR ENTITY TO PROVIDE THE SERVICE, DRUG, DEVICE OR EQUIPMENT.
TREATMENT IN THIS OFFICE MAY INCLUDE A RECOMMENDATION FOR FURTHER DIAGNOSTIC TESTING, FOR VARIOUS FORMS OF THERAPY OR TREATMENT, OR FOR DRUGS OR DEVICES. PENNSYLVANIA LAW REQUIRES YOUR PHYSICAL THERAPIST TO DISCLOSE TO YOU ANY FINANCIAL INTEREST HE HAS IN TREATMENT FACILITIES, TESTING LABORATORIES, MEDICAL EQUIPMENT SUPPLIES, PHARMACEUTICAL COMPANIES AND PHARMACIES TO WHICH HE REFERS YOU. HE MUST ALSO ADVISE YOU THAT YOU ARE FREE TO CHOOSE ANOTHER FACILITY OR ENTITY TO PROVIDE THE SERVICE, DRUG, DEVICE OR EQUIPMENT. (ACT 66-1988)
49 Pa. Code § 40.54