Medicare Patient Forms
Common Additional/Supplemental Patient Forms
Forms Specific to Women’s Health, Men’s Health and Pelvic Floor
Patient BreakThroughs
Photo/Video Waiver
Insurance Verification Sites
Nutritional Services Forms
Medicare Patient Forms
- Medications List (Required by Medicare)
- Brief Pain Inventory (Required by Medicare)
- Functional Assessment Tools (Required by Medicare for you to choose and complete the form which is most appropriate for your current condition; the one for which we are treating you)
- Back Index – for low back/lumbar patients
- Neck Index – for neck/cervical patients
- Disabilities of the Arm, Shoulder and Hand (DASH) – for shoulder, elbow, wrist and hand patients
- Lower Extremity Functional Scale (LEFS) – for hip, knee, ankle and foot patients
- Balance Assessments
*Please note that various insurance companies may require additional specific forms. As such, our Care Team will guide you to any and all required forms as needed or simply have them ready for you in the office at your first appointment.
Common Additional/Supplemental Patient Forms
- Back Index – for low back/lumbar patients
- Neck Index – for neck/cervical patients
- Disabilities of the Arm, Shoulder and Hand (DASH) – for shoulder, elbow, wrist and hand patients
- Lower Extremity Functional Scale (LEFS) – for hip, knee, ankle and foot patients
- Activities Specific Balance Confidence (ABC) Scale
- Dizziness Handicap Inventory
Forms Specific to Women’s Health, Men’s Health and Pelvic Floor
- Pelvic Floor Impact Questionnaire (PFIQ-7)
- Vulvar Pain Functional Questionnaire (V-Q)
- Pelvic Floor Distress Inventory
- Pelvic Floor Therapy Questionnaire
Patient BreakThroughs
Photo/Video Waiver
Insurance Verification Sites
- Aetna
- Blue Shield
- Anthem Blue Cross
- Blue Cross/Blue Shield
- Health Net
- UnitedHealthcare
- Tricare
- Triwest
- Medicare