Patient Forms

The link below will provide you with our patient forms. You can print these out and complete them before you come in for your first visit.

• Patient Information Form
• Patient Health History Form
• Medical History Form
• Policies and Procedures
• Notice of Privacy Practices
• Patient Insurance Verification Questionnaire
  This form is a tool for you to use to call your insurance company to verify your physical therapy benefits.

Please choose ONE of the following four functional outcome measurement forms to complete before your first visit:

• Back Index (this should be used if your problem relates to any of the following: back pain, lumbar spine problems, or pain and/or numbness radiating into your leg/thigh/buttocks/foot).
• Neck Index (this should be used if your problem relates to any of the following: neck pain, mid back pain, cervical spine problems, headaches, and thoracic spine problems, pain and/or numbness radiating into your shoulder/arm/or hand, and jaw/TMJ problems).
• Disabilities of the Arm, Shoulder and Hand (this should be used if your problem relates specifically to your shoulder, elbow, wrist or hand).
• Lower Extremity Functional Scale (this should be used if your problem relates specifically to your hip, knee, ankle or foot).

Insurance

We are providers with all major insurance companies including numerous different plans and Worker's Compensation. CPTC is certified as a rehabilitation agency under the Medicare program. Please contact one of our offices to inquire about our participation with your insurance plan.