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SCSR Therapy Forms

  1. SCSR Patient Intake/Ingesta del Paciente
  2. SCSR Compliance Agreement/Acuerdo de Cumplimiento
  3. SCSR Arbitration Agreement/Acuerdo de Arbitraje Paciente Proveedor
  4. SCSR General Release/Formulario De Liberación General
  5. SCSR Patient Finacial Responsibility Waiver - Private Insurance/Exención de Responsabilidad Financiera del Paciente: Seguro Privado
  6. SCSR Patient Financial Responsibility Waiver - Medicare/Exención de Responsabilidad Financiera del Paciente: Medicare
  7. SCSR Medical Records Request/Solicitud de Registros Médicos
  8. SCSR Attorney Medical Lien Acknowledgement/Abogado Reconocimiento de Gravamen Médico

LYG Acupunture Forms

  1. LYG Patient Intake/Ingesta del Paciente
  2. LYG Compliance Agreement/Acuerdo de Cumplimiento
  3. LYG Arbitration Agreement/Acuerdo de Arbitraje Paciente Proveedor
  4. LYG Admission and Medical Services Agreement/Admisión y Acuerdo de Servicios Médicos
  5. LYG Medical Records Release Request//Solicitud de Registros Médicos
  6. LYG Authorization of Direct Payment & Doctor's Lien/Autorización De Pago Directo Y Gravamen Médico
  7. LYG Patient Financial Responsibility Waiver - Private Insurance/Exención de Responsabilidad Financiera del Paciente: Seguro Privado
  8. 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

Personal Injury: Forms: 1, 2, 3, 4, 5 & 6

Private Insurance/Cash Patients: Forms: 1, 2, 3, 4, 5 & 7

MAIN OFFICE

1809 E. Dyer Rd. #313
Santa Ana CA 92705

Fax (949) 975-0070

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No Referral Needed

Make an Appointment

MAIN OFFICE

1809 E. Dyer Rd. #313
Santa Ana CA 92705