Please fill out the sections of the Intake form that are related to your specific case. Understand that some insurance companies continue to utlize your social security number as your personal ID number. Any omission of information my result in delay of billing or inability to bill insurance. All information is considered private and protected under the HIPPA law.
HOME
Specialized Therapy Services
Below are the intake forms which you are asked to fill out prior to your initial evaluation with Specialized Therapy Services. Please fill them out as best you can.
Please download and fill out the Activites of Daily Living forms. These are utilized to create an objective picture of how your pain levels prevent you from performing specific tasks in your life. Please answer these questions honestly. These pages are also used to help create measurable goals for your therapy sessions to help show insurance companies medical necessity.
Please fill out the Medical History form as honest and completly as possible. Please use extra paper where needed. Medical history information is considered private and protected und the HIPPA law.
Insurance plans are accepted and preferred. Other forms of accepted payment include Master Card, Visa, Cash and Check.
The State of Wisconsin requires that Occupational Therapists obtain an order (referral) for acute or recent injuries. Therefore if you need a referral please print the referral form below and give it to your referral source. You may bring it with your other forms for your evaluation or have your provider fax the form to Specialized Therapy Services at 414-778-1342. State law OT4.03(2)(b) states an Occupational Therapist may accept a referral from Medical Doctors, Advanced Practice Nurses, Physician Assistants, Chiropractors, Dentists and more. If you have any questions please call the clinic at 414-778-1341.
Myofascial Release is a hands-on approach and therefore please bring a pair of shorts and a loose fitting top (one that will allow easy access to your neck and shoulders). If you have any questions please call the office prior to your appointment.
