Welcome New Patients!

We are ready to get started serving you and your rehabilitation needs. Before we get going, we need information on the patient. Patient, medical, and insurance information need to be gathered so we can serve and treat you in the best way possible.

You will find a patient form below that you can fill out online. If you would rather download, print, and fill out the form via PDF download, you will find it under the fillable form. If you choose to do the latter, please scan it back in and upload it via the “Upload File” option under the form. If you are unable to scan to your computer, you can bring these forms with you to the office.

Attention! All Medicare patients need to fill out the “Medicare Patient Forms” and “New Patient Forms” in order for paper work to be completed correctly.

Medicare Patient Questionnaire

Medicare Patient – Therapy Questionnaire

(MM/DD/YYYY)
Please answer each of the following questions by checking YES or NO and completing the requested information:
If you answered yes, please list the name of the provider above
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New Patient Form

User Information

Patient Information

First
Middle
Last
(MM/DD/YEAR)
If patient is a student, please provide the parent's email address.
If patient is a student, please provide the parent's number.
If this is not the patients cell phone number, please provide details

Insurance Information

Financial Agreement

Medical History Questionnaire

In Case of an emergency

Patient Authorization | Consent & Release Form

Cell Phone Consent Form

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MEDICARE PATIENT NOTICE

Beginning January 1, 2006, the Government has imposed a financial limitation on the dollar amount that the Medicare Program will reimburse for outpatient therapy services received in a calendar year. This has been referred to as the Medicare “therapy cap.” The Government has created many exceptions that are available to patients so that therapy services in excess of the financial limitation may be provided for those patients that need those therapy services.

Exceptions

For the period January 1, 2016 to December 31, 2016, Medicare has set the following Financial Limitations:

For Physical Therapy or Speech Therapy services (combined) provided to you during 2016, the therapy cap is set at $1,960, which means that Medicare will pay a maximum of $1,568 for physical/speech therapy services provided to you in 2016, with the remaining $392 co-insurance payable by you or your supplemental health insurance. This payment amount is also subject to your annual $166.00 Part B deductible.

For Occupational Therapy services provided to you during 2016, the therapy cap is set at $1,960, which means that Medicare will pay a maximum of $1,568 for occupational therapy services provided to you in 2016, with the remaining $392 co-insurance payable by you or your supplemental health insurance. This payment amount is also subject to your annual $166.00 Part B deductible.

Each of the two therapy caps listed above is separately applied and measured – and each is based only on services received in 2016.

Financial Limitation

There are many exceptions to the therapy caps that allow patients to receive covered therapy services beyond the therapy cap dollar amount indicated above. If an exception is available, the therapy cap will not apply. Your therapist will discuss this with you to determine whether you may qualify for Medicare coverage beyond the therapy cap.

On October 1, 2012, Medicare implemented a new manual medical review process for some therapy services. If this new process affects you, your therapist will discuss it with you and answer your questions.

If none of the exceptions applies to you and you require additional therapy services above the financial limitation, your therapist will discuss with you your options so that you can make the best decision regarding your continued treatment.

Your care and treatment is paramount to us, and we will help you receive all of the therapy services that you require.