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Form

New Patient Intake Form

Complete the following form prior to your visit. 

New Patient Intake

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Upload File

I authorize Columbia Physical Therapy, Inc. P.S. to use and disclose health and medical information for the purposes of treatment, payment and health care operations. Under all circumstances I assume final responsibility for my account understanding that in the event my account becomes delinquent, I agree to pay accrued finance charges, court costs and attorney fees. I consent to physical therapy services prescribed by any physician. I authorize payment of medical benefits by my insurance company to Columbia Physical Therapy, Inc. PS, for
services rendered. I have received this practice’s Notice of Privacy Practices written in plain language.

What do you authorize?

Thanks for submitting! Please let us know what questions you have, otherwise we'll look forward to seeing you soon!

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