Patient Forms
	Authorization/Consent/ Financial Policy       History of Current Episode       Patient Information       HIPPA Compliance

Patient Information

What to Bring to Your Appointment

• Photo ID
• Your insurance card—primary and secondary
• Physician prescription, if required by insurance
• Physician referral/authorization form, if required by insurance
• List of medications—prescription and/or over the counter
• Information regarding your medical and surgical history
• Recent x-rays, MRI, CT Scan.

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What to Wear to Your Appointment

• Loose, comfortable clothing which permits freedom of movement and access to the body part
• Exercise or tennis shoes

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Insurance and Payment Information

• Information verification is not a guarantee of payment by the insurance company
• Co pays, coinsurance, deductibles and all other payments are due at the time of service
• The patient is responsible for any and all charges not covered by their insurance company
• The patient is responsible for knowing their insurance benefits and coverage prior to starting their physical therapy
• A private, flat-rate fee of $90 is available for direct access patients

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Cancelled/Missed Appointments

• The patient is responsible for making and verifying each scheduled appointment
• No-show appointments will be subject to a $75 no-show fee
• Cancellation without 24-hour notice will be subject to a $75 cancellation fee

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