The following forms are ONLY for patients getting ConciergeCare therapy (delivered to home) or EMG/NCS, billed directly by Guy Terry PT, OCS – Terry Rehabilitation & Testing, Inc, to your insurer. If you are going to see Guy in a physical therapy clinic, you will be given paperwork specific to that facility.
Using Adobe Acrobat, most of this paperwork can be filled in on your computer, and emailed back without printing. Use your tab key to move from blank to blank, and when you’re finished, save it, then click on “Fill and Sign” to add your signature. You can also fill it out, print, and then sign it, or you can print the blank forms and handwrite.
PLEASE answer every question. If it doesn’t apply, write “N/A” so that I know you saw it. If you are not sure how to answer, make sure you arrive early enough to get clarification and finish these forms before your appointment.
PLEASE do not fold or staple your forms. If you are able to, please print them on both sides of the paper. These forms will be scanned and shredded once you have checked in for your visit.
Read down the list – more than one category may apply. Each statement you click on will open a pdf form. Download each one, print, and fill out.
Step One – Select Your Situation
Please click on the statement that most closely resembles your situation. Download, complete, and print the paperwork:
- I was NOT injured at work OR in a car accident
- I was injured in a car accident in the past 2 years, and my claim has not yet been settled
- I was injured at work
Step Two – Identify Special Coverage Issues
Please click the category that describes to your insurance coverage:
***IF YOU DO NOT HAVE CIGNA, MEDICARE, MEDICARE, OR CHP, YOU ARE FINISHED***
Step Three – Select Your Body Part(s)
Based on the body chart below, click the number corresponding to the primary area in which you are having pain: