Forms

Thank you for choosing Peak Rehabilitation & Performance Center as your provider of quality physical therapy, athletic training, and sports medicine.

Below you will find a checklist of information we will need from you prior to your first visit with us. Forms are available for download in PDF format; to download Adobe Acrobat Reader or for help with reading the PDF document, please click here.

1) Prescription from your referring physician – describing diagnosis and frequency of visits

2) Insurance Information
In order to verify and file your insurance we will need a copy of the front and back of your primary and secondary insurance cards, as well as a copy of a picture ID.

3) Preauthorization
Please check with your insurance company to see if they require preauthorization.

4) Peak Rehabilitation & Performance Center’s Intake

5) Peak Rehabilitation & Performance Center’s Medical History

6) Peak Rehabilitation & Performance Center’s Privacy Policy

7) Peak Rehabilitation & Performance Center’s Financial Agreement

FORMS
Back Index Functional Scale
HIPAA Form
Lower Extremity Functional Scale
Neck Index Functional Scale
Patient Registration Form
Patient Questionnaire
Statement Regarding Insurance Payments
Upper Extremity Functional Scale
Patient Financial Responsibility
Medication Log