CHC Patient Forms
Listed below are the forms you will need to complete prior to receiving therapy services at our clinic. Form 1, Privacy Notice, is for your information only. Forms 2-4 can be printed, completed, and brought with you to your first appointment. Complete form 5 if services relate to a worker's compensation injury. Complete form 6 if services relate to an auto accident. Complete form 7 if services relate to a personal injury accident (See below for definition).
Additionally, please bring the following information with you to your first appointment:
- A driver's license or photo ID.
- Your insurance card(s).
- A list of all over the counter as well as prescribed medications including dosages and the frequency that you take each medication.
- Your referral/script if your physician has not already given this to us.
- If your injuries are as a result of an auto accident, please bring with you a copy of your Accident/Police report.
- Privacy Notice
This is for your information only. You do not need to bring a copy in with you, but when you sign the Release of Information/Financial Policy, you will be acknowledging receipt of this information.
- Patient Registration Form
You will need your insurance information to fill this out.
- Release of Info/Financial Policy (requires signature)
This form discloses how your medical records will be handled, your rights and responsibilities, and our policies and procedures on how we will handle your account.
- Medical History Form (requires signature)
To aid us in the selection of a proper treatment program, we ask that you complete the following health screening.
- Work Comp Form
This form is needed, in addition to the above forms, if your injury was work related.
- Auto Accident Form
This form is needed, in addition to the first four forms, if your injury was due to an automobile accident.
- Personal Injury Form
A personal injury accident is an injury that was caused by the negligence of another person or business. i.e. You fall at a retail store due to a wet floor. You notified the manager/owner and claims are being sent to this retail store's liability insurance carrier for payment. If this is the type of injury you incurred, this form is needed, in addition to the first four forms.
FOR MEDICARE PATIENTS ONLY
See descriptions following each assessment tool below to determine which form might apply to you. Complete the appropriate assessment tool taking into consideration your "worst case" symptoms within the past week.
Low Back Pain Assessment form
This form should be completed if you are being referred to our clinic for low back pain.
Neck Disability Index Assessment form
This form should be completed if you are being referred to our clinic for neck pain.
LEFS Assessment form
This form should be completed if you are being referred to our clinic for hip, knee or ankle issues.
Quick Dash Assessment form
This form should be completed if you are being referred to our clinic for shoulder, elbow or wrist issues.