SCSR Therapy Forms
- SCSR Patient Intake/Ingesta del Paciente
- SCSR Compliance Agreement/Acuerdo de Cumplimiento
- SCSR Arbitration Agreement/Acuerdo de Arbitraje Paciente Proveedor
- SCSR General Release/Formulario De Liberación General
- SCSR Patient Finacial Responsibility Waiver - Private Insurance/Exención de Responsabilidad Financiera del Paciente: Seguro Privado
- SCSR Patient Financial Responsibility Waiver - Medicare/Exención de Responsabilidad Financiera del Paciente: Medicare
- SCSR Medical Records Request/Solicitud de Registros Médicos
- SCSR Medical Lien Acknowledgement - Patient
- SCSR Medical Lien Acknowledgement - Attorney/Reconocimiento de Gravamen Médico - Abogado
LYG Acupunture Forms
- LYG Patient Intake/Ingesta del Paciente
- LYG Compliance Agreement/Acuerdo de Cumplimiento
- LYG Arbitration Agreement/Acuerdo de Arbitraje Paciente Proveedor
- LYG Admission and Medical Services Agreement/Admisión y Acuerdo de Servicios Médicos
- LYG Medical Records Release Request//Solicitud de Registros Médicos
- LYG Authorization of Direct Payment & Doctor's Lien/Autorización De Pago Directo Y Gravamen Médico
- LYG Patient Financial Responsibility Waiver - Private Insurance/Exención de Responsabilidad Financiera del Paciente: Seguro Privado
- LYG Medical Lien Acknowledgement - Patient
- LYG Attorney Medical Lien Acknowledgement/Abogado Reconocimiento de Gravamen Médico
Important Instructions! Read before you start! Instrucciones importantes! ¡Lea antes de comenzar!
If you are a patient of the following type you will need to complete and sign the form numbers listed below.
***NOTE: click on the numbers to open the forms in a new browser window and this page will stay open behind them!
PHYSICAL THERAPY:
Physical Therapy patients - please complete the forms associated with the your insurance plans below!
Workers Compensation: Forms: 1, 2, 3, 4 & 7
Personal Injury: Forms: 1, 2, 3, 4, 7 & 8
Private Insurance/Cash Patients: Forms: 1, 2, 3, 4, 5 & 7
Medicare Patients: Forms: 1, 2, 3, 4, 6 & 7
ACUPUNCTURE (LYG):
Acupuncture patients - please complete the forms associated with the your insurance plans below!
***NOTE: click on the numbers to open the forms in a new browser window and this page will stay open behind them!
Workers Compensation: Forms: 1, 2, 3, 4 & 5
MAIN OFFICE
1809 E. Dyer Rd. #313
Santa Ana CA 92705
Fax (949) 975-0070
No Referral Needed
MAIN OFFICE
1809 E. Dyer Rd. #313
Santa Ana CA 92705