New Patient Forms

Thank you for taking the time to download and complete these forms prior to your visit with us. There are numerous forms that will apply to you and we apologize for the volume of documents. Federal regulations require healthcare providers to have these in your patient file.

Today, insurance providers carefully scrutinize claims to ascertain ‘the medical necessity for therapeutic intervention’ when they review claims for payment or reimbursement. The forms that pertain expressly to you or your child’s current state of health or well being, are designed to leave few arguments or doubts in the reviewer’s mind, as to your need and justification for therapeutic intervention.

Again, thank you for your time and careful thought in the completion of these forms. We look forward to partnering with you, on your journey towards improved health and wellness…’one step at a time’.

New Patient Checklist Patient Intake Form

Revised HIPPA Privacy

Financial Policy

PIM Pain History

[If at all possible, if we could receive the Pain History questionnaire prior to your first visit, this would greatly facilitate a quality experience for you. You can either fax (847-680-5046) or email (info@power-in-motion.com). ]