Patient Forms for PT Specialists of Florence:

For your convenience, you can print the forms below to ensure that the information given to us is accurate.  If the patient is under the age of 18 a legal guardian will need to fill out the forms as well as the Adult Consent to Treat an Unattended Minor form should the guardian plan to have the patient come to treatment without them.

We know paperwork can be mundane, but please know having all of your correct information (at all times) ensures your claims process correctly through your insurance company.  If you do not have the option to print these forms prior to your appointment, they will be available at the front desk upon check-in. If you are unable to print these forms you will need to arrive 15 minutes prior to your scheduled appointment time to fill out paperwork. Please remember to read all forms carefully so you understand the information given. 

For our Notice of Privacy Practices, please click here.

You will need the following forms and items to your first appointment:

  1. New Patient Packet

  2. Adult Consent to Treat an Unattended Minor Form (should the patient be under the age of 18)

  3. Personal Injury Form (should it apply - If your visit is related to injuries sustained in a motor vehicle accident or an accident on someone else's property, please complete the Personal Injury Form and provide the correct insurance information (e.g. other party’s insurance).  Please be sure the form is completed to insure claims are processed accurately.)

  4. Worker's Compensation Form (should it apply - If your visit is related to injuries sustained at work and should be billed as Workman’s Compensation, please note that we will need prior authorization for physical therapy from your Workman’s Compensation adjuster.  You will also need to complete our Workman’s Compensation form with all necessary information prior to your appointment.  Authorization is required before your visits can be billed to Workman’s Compensation.)

  5. Your Current Insurance Card(s) & Valid ID or Driver's Licence 

  6. Your Doctor Referral/Prescription for Physical Therapy Treatment.  Some insurance company policies do not require a referral or prescription.  We encourage you to please call your insurance company to see what your plan requires.  If you want your doctor to fax your referral or prescription to our Florence clinic they can do so at 406-273-0993.