Insurance Forms
Click on form names below view forms
Client Initial Health Status Form
Auto Accident / Work Injury Form
Client Initial Health Status Form - The Client Intake Form presents all relevant client history upon
entering the office including a current injury status on initial
appointment date including relevant insurance information.
Auto Accident / Work Injury Form - The Auto Accident / Work Injury Form is for gathering detailed
information related to the injury(s) sustained in the accident and the
information needed for billing relating to auto insurance and
Workman’s Compensation.
Client Appointment Log Form - The Client Appointment Log form illustrates the date or service, relative
charges, payments received and charge description at a glance.
Chart Notes Form - The Chart Note Form illustrates the client condition on the date of service with both
visual, Lycard scale and using S.O.A.P. note forms of representation.
HIPAA Form - In accordance with the Health Information Privacy and Accountability Act (HIPAA), all
healthcare providers are required be law to maintain the privacy of your health information
and provide you a description of their privacy practices. This notice identifies your rights
regarding this offices use of your protected information. This notice also describes how
your health information may be used and disclosed and how you can get access to this
information.