Insurance / Forms

As a time savings courtesy to our customers we have compiled the insurance forms you will be required to complete prior to treatment. Click on the forms to open the documents and print them on your printer. Please complete the forms and bring them with you at your first appointment.

Adobe Acrobat PDF

You will need Adobe Acrobat to view and print the forms on this page. If you do not have Adobe Acrobat (PDF), you can click the Adobe PDF icon to download a free copy of the reader.

FREEDOM PHYSICAL THERAPY ACCEPTED INSURANCE CARRIERS

Freedom Physical Therapy is continually adding Insurance Carriers that we accept. If your Insurance Carrier is not listed PLEASE contact one of our clinics.

< Click the form on the left to download a list of insurance carriers we accept.

FINANCIAL POLICY

Freedom Physical Therapy is committed to your treatment success. Please understand that payment of your bill is considered part of your treatment.

< Click the form on the left to download a copy of our Financial Policy.

We require all our customers to read, initial and sign this form prior to receiving treatment.

BENEFIT LETTER

We use the information on this form to coordinate billings with your insurance carrier.

< Click the form on the left to download our benefits letter.

NOTICE OF PRIVACY PRACTICES

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires all health care records and other individually identifiable health information (protected health information) used or disclosed to us in any form, whether electronically, on paper, or orally, be kept confidential. As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

< Click the form on the left to download the HIPPA Notice of Privacy Practices document.

IN-NETWORK EXPLANATION

This form explains how In-Network billing is processed.

< Click the form on the left to download an explanation of how In-Network costs are processed.

OUT-OF-NETWORK EXPLANATION

This form explains how Out-of-Network billing is processed.

< Click the form on the left to download an explanation of how Out-of-Network costs are processed.

PATIENT DEMOGRAPHIC FORM

We use the information on this form to coordinate billings with your insurance carrier. This notice also describes how private information about you may be used and disclosed and how you can get access to this information. Attached is also a form authorizing the release of your medical records and/or x-rays.

< Click the form on the left to download our this form.

MEDICAL HISTORY QUESTIONNAIRE

In order to serve you better it is very important for us to learn all we can about your health condition. Please take a minute to complete this questionnaire. Your answers will be kept confidential.

< Click the form on the left to download our questionaire.