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Peak Performance Patient Policy Form
(Required) |
This form is our practice policies as it relates to release of medical information, assignment of insurance payments, promise of payment, consent to receive treatment and acknowledgement of our HIPPA policies. Please sign and date the bottom of the page. If you are under 18 years of age, please have a parent/guardian sign as well. |
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Peak Performance Patient Information Form- Columbia City Office
(Required) |
This form is your demographic and insurance data. Please provide your insurance card and photo identification for verification during your initial visit. |
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Peak Performance Patient Information Form- Warsaw Office
(Required) |
This form is your demographic and insurance data. Please provide your insurance card and photo identification for verification during your initial visit. |
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Past Medical History
(Required) |
This form is a medical history questionnaire as it may relate to your physical therapy intervention. Please check the appropriate boxes and answer any of the questions in detail if necessary. |
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Notice of Privacy Practices
(For Your Information Only) |
This form is for your records only and is a description of our patient privacy policies compliant with HIPAA. |
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Auto Accident Information |
This additional form should be printed and completed if you had an auto accident and your treatment will be billed through auto insurance. |
