Forms

For your convenience you can print the forms below to ensure that the information given to us is accurate.   If the patient is under the age of 18 a parent will need to fill out the forms as well as the Adult Consent to Treat an Unattended Minor form.

Please remember to read all forms carefully to ensure you understand the information given.  If you are unable to print these forms you will need to arrive 15 minutes prior to your scheduled appointment time to fill out paperwork.

You will need to bring the following forms and items to your first appointment:

  1.  Patient Information Form
  2.  Patient Medical History Form
  3.  Payment Policy Form
  4.  HIPPA Form
  5.  Cancellation/No-Show Form
  6.  Adult Consent to Treat an Unattended Minor Form (should the patient be under the age of 18)
  7.  Your Current Insurance Card(s)
  8.  Your Doctor Referral/Prescription for Physical Therapy Treatment (Some insurance company policies do not require a referral or prescription.  Please call your insurance company to see what your plan requires.)  If you want your doctor to fax your referral or prescription to our office they can do so at 406.777.5357.

If your visit is related to injuries sustained in a motor vehicle accident, please complete the Personal Injury Form and provide the correct insurance information (e.g. other party’s insurance).  Please be sure the form is completed to insure claims are processed accurately.
Personal Injury Form

If your visit is related to injuries sustained at work and should be billed as Workman’s Compensation, please note that we will need prior authorization for physical therapy from your Workman’s Compensation adjuster.  You will also need to complete our Workman’s Compensation form with all necessary information prior to your appointment.  Authorization is required before your visits can be billed to Workman’s Compensation.
WCOMP Form