| ||Form #1|
Health Intake Form
All clients should download this
file and complete and sign this form prior to their scheduled appointment.
This form will be reviewed to better assist the therapist in accommodating
the needs and expectations of the client.
| ||Form #2|
Patient Report Form
All new and returning patients
should fill out this form prior to each visit to help us focus your treatment
to your specific goals
All patients who have sustained injuries in a motor vehicle accident (MVA) and
wish to use their PIP car insurance benefits for massage are encouraged to
download these files.
Insurance paperwork can be lengthy and time consuming to
fill out. It would be to the benefit of both the patient and IT&B to get a head
start prior to your visit.
Prescription/Letter of Referral Form
This form should be given to
your primary care provider to fill out. Insurance claims can not be
submitted without this form. We will gladly send your primary care provider
an IT&B prescription pad at your request.
This form allows us to verify coverage and
start the billing process. Only the top portion need be completed.
Client Pain Questionnaire
This form allows us to better understand
the patientís symptoms and the severity of the injury. Please, take the time
to carefully read and sign this questionnaire.
Assignment of Benefits
This form gives the therapist permission to
bill insurance, share information with your doctors &/or lawyers, and sets
up a payment plan in case insurance companies decide to default.