Millbrook Orthopedic and Sports Therapy

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Forms

Questionnaire | HIPAA and Fees Policies | Client Forms | Insurance Forms

Please complete editable forms online. Once completed, please either print or e-mail the forms. You may print the forms, by clicking the print button located on the top and bottom of every editable form. You can then bring the completed form with you to the office. You other option is to click File > Save, to save the completed document. Then use your e-mail program to attach and e-mail the saved document to: AskMost@MillbrookPT.com.

Patient Questionnaire

We appreciate honest feedback from all of our patients regarding their experience at M.O.S.T. after they have finished their course of care.  Please take a minute to fill out this short questionnaire in the event that one was not given to you during your last visit with us. Thank you.

File Downloads

M.O.S.T. Patient Questionnaire ( PDF - 788KB)

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HIPAA and Fees Policies

Please be sure to review these policies.  If you have any questions or comments regarding the sharing of your medical records with other medical professionals involved with your case, please be specific and let us know.

File Downloads

M.O.S.T. HIPPA Practices Information ( PDF - 42KB)
Clinic Policy Regarding Visits and Fees ( PDF - 31KB)

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Client Forms

File Downloads

Patient Registration Form ( PDF - 987KB) - To be completed before initial evaluation.
Patient Medical History Form ( PDF - 745KB) - To be completed before initial evaluation.
N.Y.S. Worker's Compensation Insurance Form ( PDF - 526KB) - Worker's Comp Cases.
N.Y.S. No-Fault Insurance Form ( PDF - 517KB) - No-fault cases.
School Outreach Injury Evaluation Form ( PDF - 854KB) - Filled out if you are coming to us for a free injury screening (either at our M.O.S.T. or at your school) and you are a student-athlete.
Free Injury Screening Form ( PDF - 1.1MB) - Filled out when coming to us for a free injury screening or free consultation.
Autocharge Authorization Form ( PDF - 332KB)

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Insurance Forms

File Downloads

ACN Patient Health Questionnaire ( PDF - 985KB) - Only for use with some insurances - Ask our staff before filling out.
Back Index ( PDF - 609KB) - For Patient with Back Pain.
Neck Index ( PDF - 68KB) - For Patient with Neck Pain.
Lower Extremity Functional Scale ( PDF - 27KB) - Questionnaire for patients with lower extremity injuries.
DASH Questionnaire ( PDF - 123KB) – Questionnaire for patients with upper extremity injuries.

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