Office Forms

FM #	CATEGORY	COST
	PHYSICAL THERAPY FORMS
T-101	Recommended Treatment Plan	$12.50
T-102	Physician Evaluation Request	$13.50
T-103	Physical Therapy Prescription	$10.50
T-104	Physical Therapy Par-Q Packet (3 pg.x100)	$22.50
T-105	Physical Therapy Billing Record	$12.50
T-106	Necessity for Physical Therapy	$13.50
	OFFICE MANAGEMENT FORMS
0-101	Sign-in Sheet	$10.50
0-102	Communication Log	$10.50
0-103*	DISCONTINUED -- Set (A-E)(50 ea. A-E)
0-104	Financial Agreement A=Cash; B=HI; C=PI; D=WC; E=Medicare	$10.50 each
	CHECK LIST
0-105	Group Insurance	$10.50
0-106	Personal Injury	$10.50
0-107	Worker’s Comp	$10.50
0-108	Medicare	$10.50
0-109	Cash	$10.50
0-110	Rescheduling Reminder	$10.50
0-111	Call List	$10.50
0-112	Active Patients	$10.50
0-113	Office Statistics	$11.50
0-114	Pay Control	$11.50
0-115	Patient Payment Agreement	$12.50
0-116	New Patient Referral List	$10.50
	PATIENT HISTORY & EXAM FORMS
E-101	Radiology Report	$12.50
E-102	Case History	$13.50
E-103	Patient History Update	$10.50
E-104	Examination Report	$12.50
E-105	SOAP Notes	$12.50
E-106	Patient Information	$15.50
E-107	Consent for Chiropractic Treatment	$10.50
E-108	Patient History	$15.50
	DISABILITY FORMS
D-101	Disability Request	$10.50
D-102	Disability Release	$08.50
	PERSONAL INJURY FORMS
P-101	Medical Report	$10.50
P-102	Notice of Doctor’s Lien	$10.50
P-103	Attorney Status Report	$10.50
P-104	Rescission of Attorney Assignments	$12.50
P-105	3rd Party Medical Lien & Assignments	$12.50
P-106	Power of Attorney	$10.50
	WORKER’S COMPENSATION FORMS
W-101	Worker’s Comp Authorization	$10.50
W-102	Attending Physicians Supplemental Reports	$10.50
W-103	Final Report	$10.50
W-104	Disability Evaluation	$10.50
W-105	Itemized Statement	$10.50
W-106	Employee’s Designation of pers. Chiro (CA only)	$08.50
W-107	Employee’s Designation of pers. Physician (CA )	$08.50
W-108	Health Questionnaire (4 part pkg)	$24.00
W-109	W/C Phone Verification	$08.50
	HEALTH INSURANCE FORMS
H-101	Insurance Information	$10.50
H-102	Insurance Tracer	$10.50
H-103	Assignment & Instruction for Direct Payment	$11.50
H-104	Initial Report	$10.50
H-105	Progress Report	$10.50
H-106	Patient Report	$10.50
H-107	Progress/Examination Report	$10.50
H-108	Request for Claim Review	$10.50
	MISCELLANEOUS FORMS
ICD-9	ICD-9 Coding	$10.50
	PDI Pamphlets (25 pamphlets)	$10.45