Getting
started with The MOS
 Rehabilitation
and Physical
Therapy Center.
We at Muir Orthopaedic Specialists
know that your time is valuable. As a new patient to our
Rehabilitation and Physical Therapy facility
there are numerous required forms that you will need to complete.
We've made it easy for you when you arrive for your first
appointment by providing you all the initial forms online.
Current MOS Patients
If you are a currently a MOS patient you
should have already completed, signed and submitted a "Notice
Of Privacy Practices" document and have also filled out a
"New Patient Registration" form. If you haven't
completed those forms you can access these forms here:
Notice of Privacy Practices
This form is a 7 page pdf document that outlines how
medical information about you may be used and disclosed.
You will need to print this form, read it and bring it
with you to your next visit. DO NOT SIGN THE
FORM until you are at the MOS facility and can have
your signature witnessed. |
Click here
Adobe pdf
73K |
New Patient Registration Form
This online form needs to be completed by all
new patients and submitted 48 hours in advance of your
appointment. Once you have completed the form in its
entirety, please hit submit and this form will be sent
directly to our secure site |
Click here
online form |
Referred by a Physician Outside
MOS
or New to MOS:
If you have been
referred by a Physician outside of MOS you will need to
complete the 2 forms that appear above and then print, complete and
bring the the 4 forms listed below. These forms are provided
as Adobe Acrobat pdf forms. Simply open the form, print it, fill it out
and mail, fax or deliver it back to MOS.
Download
the Entire Packet of 4 Forms
Save yourself some time and get all 4 forms at one
time. |
Click here
Adobe pdf 138K |
|
Individual forms are
available below |
|
Physician
Ownership Form
A required
document that identifies the ownership of the
Rehabilitation and Physical Therapy facility. |
Click here
Adobe pdf
27K |
Confidential Communication Preference (Hipaa)
This document
allows the patient to specify how and to whom their
Private Health Information may be communicated. |
Click here
Adobe pdf
23K |
Patient
Medical History and Health Risk Profile
The form that gathers your
personal medical history and information that relates to
your current health risks.
This form is also
available in Spanish
by
clicking here |
Click here
Adobe pdf
101K |
Authorization for Outpatient Treatment
The form required
to authorize the MOS Rehabilitation and Physical Therapy
facility to treat you. |
Click here
Adobe pdf
10K |
For BlueShield Patients
BlueShield patients will need
to also complete the required BlueShield form(s) that relate
to your treatment. These forms are provided as Adobe Acrobat
pdf forms below. Simply open the form, print it, fill it out
and mail, fax or deliver it back to MOS.
Lower
Extremity Functional Scale
This form gathers
information having to do with any difficulty at all with
the activities listed because of your lower limb problem
for which you are currently seeking attention. Please
provide an answer for each activity. |
Click here
Adobe pdf
90K |
Back Index Form
This questionnaire will give
us information about how your back condition affects
your everyday life. Please answer every section by
marking the one statement that applies to you. If two or
more statements in one section apply, please mark the
one statement that most closely describes your problem. |
Click here
Adobe pdf
61K
|
Neck Index
Form
This questionnaire will give
your provider information about how your neck condition
affects your everyday life. Please answer every section
by marking the one statement that applies to you. If two
or more statements in one section apply, please mark the
one statement that most closely describes your problem. |
Click here
Adobe pdf
60K |
Disabilities of the Arm, Shoulder and Hand
The DASH form asks about your symptoms
as well as your ability to perform certain activities. |
Click here
Adobe pdf
65K |
Appointment
Request Form
New Rehabilitation and Physical Therapy patients
wishing to obtain an appointment can start by completing the
Appointment Request Form by
clicking
here. We will
call you back the next business day to schedule your appointment.
Your patient care and input are very important
to us. If you have any questions please contact us at (925)
939-8585.
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