Forms to Fill Out for Your Evaluation
We Have a New Online Form Now!
Old Forms to Print Out * Only if Online Form Isn't Working for You
1. Registration Form - please complete ONLINE on the WELCOME PAGE of this site
(here's a backup document in case you would like to print it).
** IF YOU COMPLETE THIS ONLINE, YOU DO NOT NEED TO PRINT THIS OUT.
| REGISTRATION |
2. Please print out, complete, and bring these forms (and additional male or female forms) with you for your first appointment. If you are not able to print out or complete, please email info@sherpelvic.com
| MEDICAL HISTORY |
| MEDICAL HISTORY #2 |
| PATIENT PRIVACY. NEEDS SIGNATURE |
| INFORMED CONSENT |
FEMALE-SPECIFIC
| female_1.jpeg |
| female_2.jpeg |
| female_3.jpeg |
| female_4.jpeg |
MALE-SPECIFIC
| male_intake_form.pdf |
THE FORMS BELOW ARE FOR ADDITIONAL INFORMATION- YOU DO NOT NEED TO PRINT THESE OUT FOR YOUR APPOINTMENT.
Worksheet for You: How to Utilize Insurance Benefits
Questions to ask your insurance provider before your first visit:
Click on the link below to open up the worksheet.
You may be eligible for reimbursement of the physical therapy charges by your health insurance company. Call customer service on your insurance card and ask these questions prior to your appointment. Some companies may reimburse you at 80%, some at 60%, some at 40%, and some may not reimburse you at all. (*Medicare does not apply to this)
You may be eligible for reimbursement of the physical therapy charges by your health insurance company. Call customer service on your insurance card and ask these questions prior to your appointment. Some companies may reimburse you at 80%, some at 60%, some at 40%, and some may not reimburse you at all. (*Medicare does not apply to this)
| Insurance Benefit Worksheet |
Billing Codes Your Insurance May Ask You to Provide
When seeking reimbursement for outpatient physical therapy, these are the typical codes used for billing. On the first visit, you will be charged an evaluation (and possibly 1-2 other charges if treatment is started). The timed charges occur in 15 minute increments. So, in one hour of treatment, typically 4 charges are billed. Your insurance customer service representative may ask for the codes used for pelvic physical therapy. This is the information you can provide. No need to search for it. It's all right here!
| Billing Codes |
Pelvic Physical Therapy Referral
(You don't need one for initial evaluation - you will need one within 30 days of your evaluation)
A referring physician can provide you with a prescription or fax one in.
It can say the following:
"Physical Therapy Evaluate and Treat"
Diagnosis Code
Date
Signature
It can say the following:
"Physical Therapy Evaluate and Treat"
Diagnosis Code
Date
Signature