VA-Referred Patient Forms

All forms are in Adobe Acrobat PDF format. Please bring them with you at the time of 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 session begins.

You can save your completed forms and email them to admin@mbmyoskeletal.com. However, this method 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 forms carefully before signing.

New Patients: Please complete Forms VA/MBM-A, VA/MBM-B, and VA/MBM-C. Please read the Form VA/MBM-D note below. If desired, please complete as much information as possible except “Records Requested” and “Purpose of Release” section.

Extended and Returning Patients: No forms are necessary if your last visit was within the past 6 months. If your last visit was more than 6 months ago, please complete Form VA/MBM-A again, even if there were no significant changes in your health.

After each visit, patient’s clinic notes will be routinely posted to the referring physician. For Manchester-Bedford Myoskeletal LLC to release to or obtain medical information from any non-VA provider: Please complete Form VA/MBM-D.

Form VA/MBM-A – VA Patient Health History – Please print, fill form out completely, sign & date.

Form VA/MBM-B – Policies – Please print, sign, & date.

Form VA/MBM-C – Informed Consent for Therapeutic Massage– Please print this form, sign & date.

Form VA/MBM-D – Medical Records Release – Please note this form is not required for us to obtain your records from or release our records including clinic/progress notes to your VA referring physician or any healthcare provider required by our contract with the Veterans Administration. 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 or release any portion of your medical records elsewhere, OR you want us to speak with a specific non-VA physician or other healthcare provider about your concerns. No form is required for us to render relevant information about your case to the next of kin named on your Health History form, an emergency room contact, or any emergency transport personnel in the event of a medical emergency. However, we will not release clinic notes to anyone including those named above without this Release.

Form VA/MBM-E – Self-Pay Single Visit Agreement – Only complete this form to request a single self-pay office visit to Manchester-Bedford Myoskeletal LLC. This form must be completed and signed by the patient at least 48 hours prior to the desired visit. Patient pays 100% of our fees. VA will NOT be responsible for any portion of this visit.

Form VA/MBM-F – Self-Pay Agreement – Complete this form only if you are a VA-referred veteran desiring three or more self-pay visits at Manchester-Bedford Myoskeletal LLC for assessment, re-assessment, or treatment. This form must be completed and signed by the patient at least 48 hours prior to the first self-pay desired visit. Patient pays 100% of our fees. VA will NOT be responsible for any portion of this visit.

Click here to view our Notices of Privacy Practices and Patient Rights forms. You may print a copy for your records. You are also entitled to obtain a copy from our office upon request.