You have the option to download the Medical History, Financial Responsibility, Consent to Treat, and HIPAA Privacy Notice forms below. You may choose to complete each form and bring all five forms to your first visit or you may complete the paperwork in our office.
Our staff will be happy to assist you with this paperwork!
Please bring the following items to your first appointment:
- Your most current insurance card(s)
- Your Picture ID
- Prescription/referral for therapy from your health care provider (Required by most insurance)
- Current medication list
Our staff will verify your insurance coverage prior to your first visit.
You may elect to self-pay for your therapy. (Doctor’s prescription is not required, if self-pay)
Please plan to be in our office for at least one hour.
Download Medical History Form
|This form is your past medical history for your physical therapist. Please make sure you fill out all sections.|
Download Financial Responsibility Form
|This form explains Active Solutions Therapy payment policy and the patient’s financial responsibility.|
Download Consent To Treat Form
|This form allows Active Solutions Therapy permission to treat you for the condition diagnosed by your physician, assignment of medical benefits, and allows direct payment from your insurance company.|
Download Cancellation and No Show Policy
|This form explains Active Solutions Therapy policy on cancelling or not showing up for an appointment.|
Download HIPAA Privacy Notice
|As compliant with HIPAA Laws we will not release any of your medical information without your consent.|
What to expect on your first visit:
- Your therapist will perform a detailed examination evaluating your condition and therapies that may be beneficial including the possibility of manual therapy including massage, exercises specifically designed for your condition and goals, and give you ideas about how to self manage your condition. Modalities including electrical stimulation, ultrasound, and/or anti-inflammatory treatments may be beneficial.
- Your therapist will tailor your program to fit your needs.
- You may be able to begin treatment at your first visit.
- Please bring or wear loose fitting comfortable clothes. If possible, wear clothing that can expose the treatment area. A hospital gown and shorts can be provided as well.
If you have any questions regarding these forms please contact our Albuquerque, Edgewood or Cedar Crest locations HERE.