GIVEN SPORTS & PHYSICAL THERAPY
NEW PATIENT FORMS
Complete and bring to Your First Visit
HEALTH INSURANCE & SELF-PAY
Use this link if you have any insurance besides the others noted (ie BCBS, Aetna, Multiplan, PHCS, Humana, UHC) or are a self-pay patient.
Please note that most Cigna plans in Illinois require services to be billed to American Specialty Health. The enclosed forms are needed in order to acquire an authorization for therapy.
Download these forms if we are filing claims for workers' compensation on your behalf.
NOTICE OF PRIVACY PRACTICES
We are obligated to notify you about how we safeguard your privacy. There is no need to print this form or to bring it to your therapy appointment.