At Lifespan Physical Therapy, Occupational Therapy, & Speech and Language Pathology Services, PLLC, we want to make your visit as easy as possible. Patient Forms are provided to download, print, and complete prior to visiting for the first time. Please bring forms with you.
New Patient Forms
- PATIENT REGISTRATION FORM- GENERAL INS
- PATIENT REGISTRATION FORM- WORKERS COMP, NO FAULT
- Patient Health Questionnaire
- Disclosure of PHI to Designated Individuals Form
- Notice of Privacy Practices
- Acknowledgement of Receipt of Privacy Practices
- Medicare Financial Limitation Notice 2016
Specific Injury Forms
The following forms are specific to type of injury or body region to be addressed. Please print the form pertinent to your need, complete, and bring with you on your first visit. These forms are required for Medicare, Empire, MPN, No Fault, and Worker’s Compensation only.
Release of Information Form:
If you would like Lifespan Therapies to release your therapy record in part or whole to a professional of your choice, please complete the following form and return it to our office.
Please contact our office at 315.364.7570 for further assistance if required. Thank you.
To download forms, access Adobe Acrobat here.