Please arrive for your first appointment 15 minutes early for check-in and insurance verification. Download, print, and complete the applicable forms to bring to your first appointment. Descriptions of the forms are also provided below.
NEW PATIENT PAPERWORK FORMS:
- Non-Medicare Patients – Click here to download the forms
- Medicare Patients – Click here to download the forms
- Under 18 Patients – Click here to download the forms
- 3M Clinic ONLY Patients – Click here to download the forms
- Medical History Form – This form must be completed by all new and returning patients. It gives us important information that your therapist needs to develop a treatment plan for your therapy.
- Medication List Form – Provides us with information on medication name, dosage, reason for taking, frequency, and how it is taken. This is important for your therapist to know in developing your treatment plan.
- HIPAA Form – This form describes how the health insurance information that you provide may be used and disclosed. This is required by the Health Insurance Portability and Accountability Act of 1996.
- Cancel / No Show Policy – This describes OSI’s policy on appointment cancellations and/or not arriving for your appointment. Consistent attendance allows you and your therapist to progress your treatment program.
- Medicare Cap Information Letter – This is informational only, and does not require a signature. It describes the annual financial limit (cap) on therapy services that Medicare has in place.
- Consent For Minors – OSI requires that a parent or legal guardian accompany any minor children to their medical appointment. If a parent is unable to accompany a minor child to an appointment, the parent or legal guardian must sign this form.
Request More Information
ALSO PRINT THE FOLLOWING FORMS IF THEY APPLY TO YOU:
PELVIC FLOOR PATIENT:
- Pelvic Dysfunction Questionnaire – Click here to download the form – This form provides additional medical history information for your therapist.
- Bladder and Bowel Symptom Questionnaire – Click here to download the form – This form provides additional medical history information for your therapist.
- Consent for Evaluation and Treatment Form – Click here to download the form – This form gives consent for a pelvic floor examination.
PHYSICIAN FORMS:
REFERRAL FORM
This form is available for physicians to download if they run out of referral pads – Click here to download the referral form –
If you are a physician and need more referral pads, please contact Brenda Estrada at bestrada@osipt.com
