Intake & HIPAA Forms

This can be completed via a link once you schedule an appointment with us! It will ask for demographic information, along with a completion of our policy statement and HIPAA form. 

Privacy Statement

This describes how medical information may be used and disclosed, and how you can gain access to it. This is not needed for your appointment.

Click Here to Download 

Good Faith Estimate Statement

If you are uninsured or decide not to file a claim with your insurance company, you have the right to receive a Good Faith Estimate for your Physical Therapy services. We would be happy to provide an estimate in writing prior to your appointment. Please contact us so we can share our current fee schedule with you. If you receive a bill that is higher than the Good Faith Estimate provided to you, please contact our office and we would be happy to discuss it. You also have the right to dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate for your records. 

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 785-621-5888.