Patient Information - Centralia

Please print and fill out the following forms to bring with you to your first appointment:

 

• Medical Questionnaire
• Patient Information

 

Please also choose the appropriate form from below based on your therapy needs:

 

• Lower Extremity Functional Scale: for hip, knee, ankle, foot, leg pain or disability.
• Modified Oswestry: for low back pain or disability
• Neck Pain Disability Index: for neck or mid back pain or disability
• Quick DASH Test: for shoulder, elbow, wrist, or hand pain or disability

 

If you have one of the insurance plans listed below, the appropriate form is also needed:

 

• Regence/Uniform Incident Report
• Premera Incident Questionnaire
• Lifewise Incident Questionnaire

 

Please bring these completed forms with you to your first appointment, along with your:

 

• Photo ID
• Insurance card(s)
• Physician’s prescription/referral for Physical Therapy

 

Insurances We Accept

 

We are contracted and participate with most local and national insurance plans. For questions regarding which plans we accept, please contact our front office at 360.736.5273.

 

OCR HIPAA Privacy Practices

 

You are free to read and review this notice at your convenience. Read OCR HIPAA's Privacy Practices here.

 

 

CPT Privacy Practices

 

You are free to read and review this notice at your convenience. Read CPT's Privacy Practices here.