Patient Service Forms

For your convenience, we offer our patient forms online. Please feel free to print the below forms and have them completed prior to your visit.

General Patient Forms
(Available in Adobe PDF and MS Word):

1. Medical Intake Form :
   Glover Physical Therapy requires each patient's medical history through the medical intake form.



2. Authorization for Release and Disclosure Form:
   Although Glover Physical therapy does not require this form to be signed by each patient, if you choose not to sign it we would not legally have the ability to share your medical information regardless of the circumstance.



3. Cancellation Policy Form :
   Glover Physical Therapy requires each patient to also sign our cancellation policy & financial responsibility forms.



4. Financial Responsibility Form :

Patients with the following insurance(s) please print & fill out accordingly:

1. No-Fault Info & Billing Agreement Form :
   The No-fault info & billing agreement is for patients with No-Fault insurance.



2. Workers Comp Info & Billing Agreement Form :
   The Workers Comp info & billing agreement is for patients with Workers Comp insurance.



3. Signature on File Form :
   The signature on file form is for patients with Medicare insurance.

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