INTEGRATED PHYSICAL THERAPY SERVICES, INC.

Patient Registration Form

Collects pertinent information to allow us to contact you and to bill for therapy services

Health History / Review of Systems Form / Condition Assessment Form / Condition Assessment Form

Collects necessary information to initiate evaluation process

Identifies and objectifies symptom type & location

Collects necessary information to facilitate determination of a therapy diagnosis

 Release of Information and Consent for Treatment / Assignment of Benefits / Payment Guarantee Form / Notice of Privacy Practices (HIPAA Acknowledgement Consent) Form

Financial Policy

Medicare Secondary Payer Form

Wellness Program Registration Form

In accordance with our goal to preserve an evidence based practice, you may have to complete additional functional activity form(s) to allow us to further diagnose your condition as well as facilitate future measurement of therapeutic outcomes.