Patient / Client Forms | BreakThrough Physical Therapy

Sports and Wellness Client Forms
New/Returning Patient Forms
Medicare Patient Forms
Telehealth Forms
Common Additional/Supplemental Patient Forms
Forms Specific to Women’s Health, Men’s Health and Pelvic Floor
Forms Specific to MVA or Personal Injury
Patient BreakThroughs
Photo/Video Waiver
Insurance Verification Sites
Nutritional Services Forms

Sports and Wellness Client Forms

Sports and Wellness Client Forms (required for all sports performance, wellness, Golf, and video analysis clients)
FMS Client Forms (required in place of the above “Sports and Wellness Client Forms” when doing FMS)

New/Returning Patient Forms

New/Returning Patient forms (required for all patients, except Medicare and Auto Claims)
New/Returning Patient forms (Self Pay)
New/Returning Patient Out of Network (full packet)
New/Returning Patient Out of Network Acknowledgment
Auto Claim Patient Registration Forms (only for patients requesting that we bill through their Auto Claim)

Medicare Patient Forms

Medicare Patient Registration 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
  - Activities Specific Balance Confidence (ABC) Scale

*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.

Telehealth Forms

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

Sports and Wellness Client Forms

New/Returning Patient Forms

Medicare Patient Forms

Telehealth Forms

Common Additional/Supplemental Patient Forms

Forms Specific to Women’s Health, Men’s Health and Pelvic Floor

Forms Specific to Motor Vehicle Accidents/Injuries (MVA/MVI) or Personal Injury (PI)

Patient BreakThroughs

Photo/Video Waiver

Insurance Verification Sites

Nutritional Services Forms

Bay Area Nutrition, LLC