Who Can Benefit From Physical Therapy?

Physical therapy can help any age group with:

  • Low back pain
  • Neck pain
  • Shoulder and arm pains
  • Sprains and strains
  • Arthritis
  • Cardiac Rehabilitation
  • Rehabilitation after a serious injury
  • Pediatric concerns
  • Stroke Rehabilitation
  • Problems with balance and falls
  • Pre/postnatal programs
  • Hip fractures
  • Pre and post surgical rehabilitation
  • Sport and work related injuries

Patient Information Form

Date
Name
Email
Patient SS#
Patient's Legal Guardian
(if under 18 years old)
Address
Home Phone
Work Phone
Date of Birth
Age
How did you hear about this office
May we contact you at work? yes no
Can we leave messages on home answering service? yes no
Can we send post-card mailers to the above address yes no
Primary Care Physician Phone#:
Name of Referring Physician Phone#:
Emergency Contact Name Phone#:

Insurance Information

Primary Insurance Company Name
Primary Insurer's Name
(& relationship to patient)
Primary Insured DOB
Primary Insured SS#
Policy #
Employer
Secondary Insurance Company Name
Primary Insurer's Name
(& relationship to patient)
Primary Insured DOB
Primary Insured SS#
Policy #
Employer

(Please provide insurance card so that copies can be made for billing purposes)

Assignment of Insurance Benefits

The undersigned hereby authorizes the release of any information relating to all claims for benefits submitted on behalf of myself and/or dependants. I further expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim to be submitted for myself and/or dependents, and that I will be bound by this signature as though the undersigned had personally signed the particular claim.

I   (name of insured)   hereby authorize
(name of insurance company)
to pay and herby assign directly to Complete Rehab Therapy all benefits, if any, otherwise payable to me for his/her services as described on the attached forms. I understand I am financially responsible for all charges incurred. I further acknowledge that any insurance benefits, when received by and paid to Complete Rehab Therapy will be credited to my account, in accordance with the above said assignment.