Patient Forms

Veterans Administration-referred patient forms redirect here.

All forms are in Adobe Acrobat PDF format and will require that you have that software. Please bring the completed forms with you to your first visit. Alternatively, you may complete these forms when you arrive at the clinic for your initial visit. All required forms must be completed before your initial visit begins.

Completed forms may be faxed securely to us at (888) 965-6870. Emailing completed forms to admin@mbmyoskeletal.com is NOT recommended because email is not a secure medium and is NOT HIPAA compliant. Your information, once in our hands, will be kept strictly confidential.

Please read all forms carefully before signing.

New Patients: Please use the links below to download and complete Patient Information, Consent to Treat / Consent to Bill, and Patient Health History.

We highly recommend patients read our clinic Policies. You can save and/or print a copy for your records. Scheduling an appointment with us indicates that you’ve read, understand, and agree to our policies. If you have any questions about our policies or any form, please contact us. If you do NOT agree to our policies, do not schedule an appointment.

If you wish us to file insurance claims on your behalf, please follow the instructions on the Patient Information and Insurance Claim Information forms below. We are NOT able to file claims with Medicare, Medicaid, Medicare Supplement, or Medigap programs, or commercial HMO plan policies. We can bill certain Part C Medicare Advantage programs. Call the member services phone number on the back of your insurance card and ask if you have out-of-network massage therapy benefits. For more detailed insurance information, please select the Insurance option under the Patients tab at the top of your screen.

Returning Patients: No forms are necessary if your last visit was within the past 12 months and your information and health history has not changed. If your last visit was more than 1 year ago or if any of your information has changed, please complete Patient Information and Patient Health History forms again.

If you want Manchester-Bedford Myoskeletal LLC to release any portion of your clinic records to anyone other than your insurance company or if you want us to obtain any medical information from another provider (imaging, diagnosis, records, etc.) for review in this office: Please complete Medical Records Release Form.  Please understand that no confidential information will be released by us to anyone without this completed form unless another provider sends their own release form with your signature to us.

We are in the process of designing new PDF fillable forms. Some of the forms below have already been updated and patients are able to fill them out on-screen, print them, and sign. If the form does not appear fillable, please print, sign, and date. Be sure to read each form carefully.

Patient Information – Please fill out as directed & sign.

Consent to Treat / Consent to Bill – Please print this two-page form, sign and date Consent to Treat section. Sign and date the second section, Billing Authorization, only if you want us to file medical insurance claims on your behalf.

Patient Health History – Please fill out both sides completely and sign.

Medical Records Release – Please complete this form if you want us to release any portion of your file to your designee or if you want us to obtain any portion of your medical records from another provider’s office.

Insurance Claim Information – If you have not been formally referred to us by your doctor but wish us to file claims with your health insurance company, please print this form and ask your physician’s office for this information or ask them to fill it out for you and bring it with you to your appointment here. No signature is required. If your physician’s office declines to provide the information, your claim may be denied by your insurance company. We are NOT able to file claims with Medicare, Medicaid, Medicare Supplement, Medigap, or any HMO insurance plans.

Click here to view our Notices of Privacy Practices and Patient’s Rights and Responsibilities. You may print copies for your records. Copies are also available from our office upon request. The law does not require us to comply with HIPAA laws or regulations. However, we take our confidential relationship with our patients seriously and endeavor to comply as closely as practicable. No signature is required for this form.