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Patient forms and Insurance information 

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Patient Forms
All new and returning patients will need to print and complete the Patient Packet forms, one of the specific injury location forms below (ex: back pain, knee pain), and the WC/Liability form if applicable.  Please bring these completed forms along with your insurance card and drivers license to your initial appointment.

• Patient Packet​

​Neck Pain
Do you have neck pain? Please complete this form - Neck Index
Upper Extremity Pain
Do you have shoulder, elbow, wrist or hand pain? Please complete this form - Quick Dash 
Back Pain
Do you have low back pain? Please complete this form - Oswestry LBP Questionnaire 
Knee Pain
Do you have knee pain?   If you are 55 or younger or a runner fill out this form - LEFS
                                               If you are over 55 and a non-runner fill out this form - KOOS
Hip Pain
Do you have hip pain?     If you are 55 or younger or a runner fill out this form - LEFS
                                              If you are over 55 and a non-runner fill out this form -  HOOS  
Ankle Pain
Do you have foot or ankle pain? Please complete this form - Foot and Ankle Disability Index
Balance Problems
Do you have trouble with your balance or gait (walking)? Please complete this form -  MFES 

Worker's Compensation
If you are being seen for a work related injury, please fill out the following worker's compensation form.

• Worker's Compensation Form

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Third Party Liability
If you are being seen for an injury that is the fault of another individual and will be filed under their liability
insurance, please fill out the following Liability Form.

• ​Third Party Liability Form

Medical Release Form​
Fill out and return the release form. 

• Medical Release Form

​HIPAA Notice of Privacy Practice
If you are interested in reading our HIPAA Notice of Privacy Practices information please click on the link below.

• HIPAA Form

Insurance Information
Snyder Physical Therapy & Sports Rehabilitation is a preferred provider for most insurance plans. We accept many insurances that are not listed below. Please take a moment to check with your insurance to verify your outpatient physical therapy benefits and eligibility. You will be responsible for any deductibles, co-pays, coinsurance and any other services considered non-covered by your plan.

• Aetna
• Automobile Injury Insurance
• Blue Cross Blue Shield
• Coventry Healthcare
• Medicaid
• Medicare
• Medicare Advantage
• Midlands Choice
• Mutual of Omaha
• Mutually Preferred
• Private Healthcare System
• Tricare/TriWest
• Workers Compensation
• United Healthcare​