Syracuse Physical Therapy


ORTHOPEDIC REHABILITATION AND SPORTS MEDICINE



Helpful Forms


Please review ALL forms on this page and print the forms which best pertain to your injury

I
f you're a new client, please complete the following forms and bring them to your first appointment. 

 

        Patient Information Conset Form
         Designated Individual Authorization Form


Please print out and complete the following form(s) which match best with the body area injured.   These forms are used to measure and track overall functional level throughout physical therapy.   

          Disabilities of the Arm, Shoulder, and Hand
          Lower Extremity Functional Scale - (Hip, leg, foot)
          Back Index
          Neck Index


If you will be receiving physical therapy for injuries sustained in a motor vehicle accident, please print and complete the following form.

         
         NYS Motor Vehicle No-Fault Insurance Law (Assignment of Benefits Form) 


Medicare patients - please print out and review the following forms prior to attending your first visit.  If you have any questions, please notify one of our staff upon your arrival.

          Medicare Financial Limitations Notification Form
          Yearly Medicare Notification Form


If you would like our team to coordinate care with another physician practice please complete the form below to authorize release of your medical records
 

 


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