Online Form | Physical Therapy Associates

Patient Information

Patient Employer Information

Primary Insurance Information

Secondary Insurance Information

Medical Information

In the past 3 months have you had or do you experience the following (Choose Yes or No)


List ALL current prescriptions, over the counter medications, herbal, vitamin/mineral/dietary (nutritional) supplements

MEDICATION NAME DOSAGE (ex. mg,ml, cc) FREQUENCY (ex. 3 times a day, 5 times a week) ROUTE OF ADMINISTRATION (ex. oral, injection, topical)

DUE TO FEDERAL PRIVACY RULES (HIPPA) we cannot speak to anyone other than yourself regarding your treatment or bill without your consent. Please indicate the person(s) that you are authorizing us to release your personal protected health information to:

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPPA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly or indirectly.
  • Obtain payment from third-party payers
  • Conduct normal healthcare operations such as quality assessments and physician certifications.

I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Private Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide in such restrictions.

I authorize my insurer to pay any benefits for services rendered directly to Physical Therapy Associates. I understand that anything not covered by insurance is my full responsibility. I hereby authorize Physical Therapy Associates through it’s appropriate personnel to perform on me, or the patient named above, appropriate assessment and treatment procedures relating to my diagnosis.