Forms & Insurance

At Brevard Therapy & Physical Medicine, we value your time and we respect your privacy. Below, you will find our new patient forms, which you can download, fill out, and bring into our office at the time of your first visit. This will expedite the process for new patients. We have also provided links to our partner insurance provider web sites, where you can check your benefits and access other forms that may be required for reimbursement of medical claims.

Of course, if you have any questions or concerns, please feel free to call our office for assistance.

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NEW PATIENT FORMS:

Application for Auto Accident (FOR AUTO INSURANCE CLAIMS)

Application for Major Medical (1) ( FOR HEALTH INSURANCE AND SELF PAY)

Informed Consent Chiro

Medical Report & Lien (FOR AUTO ACCIDENT PATIENTS ONLY)

Permission to share records

RELEASE OF MEDICAL RECORDS

STANDARD DISCLOSURE

 

 

Our Partner Insurance Providers

Aetna
Beech Street
Blue Cross/Blue Shield
Cigna-PPO
GHI
Health First
Humana
Medicare
PHCS
United Health Care
All automotive insurances
Cash Plans Available
And others (please call to inquire)