Patient Forms
Insurance
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.
All new 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 to your initial appointment.
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.
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.
HIPAA Notice of Privacy Practice
If you are interested in reading our HIPAA Notice of Privacy Practices information please click on the link below.
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
All new 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 to your initial appointment.
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.
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.
HIPAA Notice of Privacy Practice
If you are interested in reading our HIPAA Notice of Privacy Practices information please click on the link below.
