For your convenience, we have included links to our intake paperwork, records request, and administrative forms. We use DocuSign to ensure patient privacy and streamline our paperless workflow. If you download and complete the forms before receiving them from our team, please email the completed documents to reception@quinnpt.com.
PATIENT INTAKE FORMS
Please download and fill out all the forms in this package, including the Acknowledgement of Receipt of Notice of Privacy Practices, Consent to Treat, and Agreement of Financial Responsibility. These documents must be signed each time a new plan of care is established for treatment.
Our privacy policy can be read here: Notice of Privacy Practices
If you are a Medicare insured patient, please download and fill out all the forms in this package. In order to bill your insurance correctly, in addition to the New Patient Intake two more intake forms are required as mandated by Medicare (refer to Medicare Packet & Notice to Medicare Patients).
Our privacy policy can be read here: Notice of Privacy Practices
If receiving Pelvic Floor Physical Therapy services, please download and complete this additional consent form. Please find additional information about Pelvic Floor Treatment on our FAQ page.
ADMINISTRATIVE FORMS
To manage your health information securely and accurately, please choose and complete the appropriate form based on your request. Once completed, please submit the form to our office.
QOPT Authorization for the Release of Protected Health Information
Medical Record Amendment/Correction Request Form
If you have any questions or need assistance with these forms, please contact our office staff for guidance. Thank you for your cooperation.
