Patient Forms

If you still have any questions on which forms to complete or on the forms themselves, please don't hesitate to contact us.

General Patient Forms:

Please click on the name of a form to download it as an Adobe PDF (requires Acrobat Reader which can be downloaded for free here)

1. Patient Registration: Please complete, sign, and return to us. This form requires you to complete information such as demographics, Insurance, Emergency Contact, Referring and Primary Care Physician Name and Phone Numbers.



2. Patient History Form (s): Please complete, sign, and return to us. This form is to educate our Therapists and/or your Insurance Company so that they can better understand your needs. (If you are a Medicare Patient please refer below for additional forms)
   
   • Medical History Form
   • Pediatric History Form
   • Adult and Sports Injury History Form
   • Pediatric Speech History Form
   
   
3. HIPPA: Please read this very carefully and take this copy for your records. This form explains how medical information about you maybe used and disclosed and how you can get access to this information.



4. Authorization for Disclosure of PHI: Please complete, sign, and return to us. We are required to get your permission to communicate with healthcare professionals, school personnel, etc where it pertains to you or your child's care.



5. Financial Payment Policy: Please read this very carefully and take this copy for your records. This policy explains important information regarding cancellation fees and your financial responsibility as the insurance holder.



6. Copayment vs. Coinsurance Info: Please read and take this copy for your records. This sheet is to help you understand what it means when your insurance company says you have a "copayment" or a "coinsurance payment."



7. Patient Authorization: Please read, sign in the blocks provided, and return to us. This Authorization states that you give us permission to treat you, bill your insurance, you have read our HIPPA policy, you have read our Financial policy, and you give us permission to use Media Recording (pictures, videos of you or your child) while you are receiving treatment.
   



8. Upper Extremity Funcational Index: Complete for pain in the mid to upper back region and above.
   



9. Lower Extremity Functional Index: Complete for the pain in the mid to lower back region and below.
   



10. Auto Accident - Assignment of Benefits: Please read, sign in the blocks provided, and return to us.
    

Medicare Patient Forms:

1. Medicare Financial Responsibility Disclosure: Please read, complete, sign, and return to us. As a Medicare Provider we are required to inform you about your responsibilities as a Medicare Beneficiary.



2. Therapy Questionnaire: Please complete, sign, and return to us. Medicare requires that we ask these questions prior to treating new patients.



3. ABN Frequently Asked Questions: Please read and take this copy for your records. This Medicare policy explains important information regarding denial of payment by Medicare in some circumstances.