Get Ks Pt Plus Patient Intake Form 2018-2025

Completing the KS PT Plus Patient Intake Form online is an essential step in receiving quality physical therapy services. This guide provides clear instructions to help you navigate each section of the form, ensuring a smooth and efficient process.

Follow the steps to fill out the form accurately

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your primary care physician's name and referring physician's name in the respective fields, if applicable. If your injury is work-related, indicate 'Yes' or 'No' in the designated section.
3. Provide information on how you learned about PT Plus by selecting one option from the list, such as 'Direct Mail', 'Your Physician', or 'Friend', and fill in related details if necessary.
4. Indicate whether you have received any kind of home health care in the past three months by checking 'Yes' or 'No'. If you answer 'Yes', remember to notify the front desk during your appointment.
5. Fill out your personal information in the 'Patient Information' section, including your legal name, mailing address, date of birth, age, social security number, home phone, cell phone, and email address.
6. If applicable, provide information about your employer and work-related details, including the business name, address, phone number, and occupation.
7. In the 'Spouse Information or Card Holder Information' section, fill out the legal name, mailing address, date of birth, and social security number of your spouse or cardholder, or indicate that it is the same as your information above.
8. Complete the 'Insurance Information' section by providing the names of your primary and secondary insurance providers. If you do not have medical insurance, ensure to check the corresponding box.
9. Designate an emergency contact other than your spouse in the 'Urgent Care Information' section. Enter their name, address, and relationship to you.
10. Review the release and assignment information, ensuring you understand the authorization for PT Plus to release your medical information. Sign and date the form at the end, either as the patient or legal guardian if under 18 years old.
11. Once all fields are completed, you may save your changes, download the completed form, print it out, or share it as needed.

Take the next step toward your health by completing your forms online today.