Forms
Professional Quality Care, Close To Home
At Henniker Physical Therapy, these essential forms ensure a smooth start to your care. They collect key medical information, clarify insurance requirements, outline clinic policies, and explain billing procedures — all designed to help us provide safe, effective, and personalized treatment.
Medical History Form
This form gathers essential patient information relevant to physical therapy, including details about physical limitations, pain levels, past injuries, surgeries, chronic conditions, medications, and other health issues that could affect treatment. It also asks about daily activities such as driving, sleeping, mobility, and tasks like kneeling or lifting, providing therapists with a comprehensive view of a patient’s functional abilities and medical background.
Home Health Care Acknowledgement
This short declaration confirms whether a patient is currently receiving home health care services. By signing, the patient acknowledges that if they are receiving such services, Medicare and possibly other insurers will not cover outpatient physical therapy, and they will be financially responsible for those costs. It ensures patients understand their insurance coverage obligations before treatment begins at Henniker Physical Therapy.
HPT Welcome Form
This welcome document introduces patients to Henniker Physical Therapy’s services and emphasizes the clinic’s commitment to quality care in a supportive environment. It explains policies around appointment cancellations, insurance responsibilities, and encourages patients to communicate openly about their treatment plans. The form sets expectations for patient engagement and administrative procedures from the start of care.
General Billing Policy Form
This detailed form outlines the clinic’s billing procedures, including payment expectations for copays, coinsurance, and deductibles, as well as timelines for insurance processing and patient billing. It explains factors influencing treatment costs, such as time, procedures, and equipment, and discusses policies on overdue balances and initial evaluation charges. The form advises patients to understand insurance plans and serves as an invitation to discuss any billing concerns proactively.
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