This informed consent form provides you with the necessary information about the therapy services offered by Prava Therapy, including in-home and virtual (telehealth) care. Please read this document carefully and provide your consent before starting treatment.

A. Treatment Information

Therapy services provided by Prava Therapy may include evaluation, assessment, diagnosis (where applicable), and treatment of conditions affecting physical function, mobility, communication, cognition, behavior, and activities of daily living. Services are delivered by appropriately licensed or certified healthcare professionals within their respective scopes of practice.

While therapy can lead to meaningful improvements in function, independence, communication, behavior, and overall quality of life, there are potential risks, which may include:

• Temporary discomfort or soreness

• Fatigue

• Frustration during skill acquisition or behavioral intervention

• Temporary increase in symptoms

• Rare exacerbation of underlying conditions.

You acknowledge that the success of therapy is largely dependent on your active participation, and while we strive to achieve the best possible outcomes, no guarantees can be made regarding specific results.

B. In-Home Care

For patients receiving in-home therapy:

• A licensed therapist will come to your residence to provide treatment. You must ensure that the treatment area is safe and accessible.

• The therapist may need access to equipment and sufficient space to perform therapeutic exercises.

• You are responsible for communicating any discomfort or issues experienced during the session.

C. Virtual Care (Telehealth)

For patients receiving care via telehealth:

• Telehealth sessions will be conducted using secure, HIPAA-compliant video conferencing tools.

• There are unique risks associated with telehealth, including technical difficulties, limitations of remote treatment, and potential confidentiality breaches due to the electronic transmission of information.

• You acknowledge that telehealth is subject to the same standards of care as in-person treatment, but the format may limit certain aspects of the physical examination and treatment process.

• In the event of technical issues, an alternative communication plan (such as a phone call) will be discussed with your provider.

D. Confidentiality

Your privacy is of utmost importance. All communications and treatment records will be kept confidential in accordance with HIPAA regulations and Prava Therapy’s Notice of Privacy Practices. There are situations where we may be required by law to disclose certain information (e.g., in cases of abuse, neglect, or imminent danger).

E. Financial Responsibility

You understand that you are financially responsible for charges that are not covered or paid by your insurance. You hereby consent to the release of information to third-party payors or their representatives as deemed necessary by Prava Therapy to determine benefits entitlement and to process payment claims for services provided. You authorize and direct that payment of any health insurance or healthcare benefits otherwise payable to you for health care services will be paid directly to Prava Therapy for the charges for which Prava Therapy is authorized to bill in connection with the services provided to you. You certify that the information given by you in applying for payment is correct. You acknowledge full responsibility for, and agree to pay, all charges not otherwise paid by your insurance company or other payor. Charges are due and payable upon receipt of the bill. If you have questions, you are encouraged and expected to ask them before you acknowledge this form. Your acknowledgement of this form indicates that you have read and understand this document and that you have had the opportunity to ask questions about anything in this form. By acknowledging this Informed Consent, you confirm and agree to the following:

F. Physician Engagement

I authorize Pravay Therapy, or my assigned therapist, to notify my physician for any required approvals or prescriptions related to my care. Additionally, I authorize Prava Therapy to share my health information with any engaged therapy clinic to facilitate my treatment and payment for services.

G. Acknowledgment and Consent

By signing this form, you acknowledge that:

• You have received detailed information about the nature, purpose, risks, and benefits of therapy, including in-home and virtual care.

• You understand that participation in therapy is voluntary and that you may withdraw from treatment at any time.

• You understand that telehealth services may have limitations, and you agree to proceed with such services.

• You authorize Prava Therapy to release necessary health information to insurance carriers or other payors as required.