Forms & Documents...
The forms listed on this page are for your reference. You can fill them out ahead of time if you wish, or you can fill them out at our office.
All patients must fill out forms marked with * prior to treatment.
Only Medicare patients must fill out forms marked with ** prior to treatment.
Click on the links below to download a PDF version of the form. Click here to get Adobe Reader.
>> Admittance Form *
This is the form that you will need to fill out for admittance.
>> Assignment of Benefits *
This form is for the assignment and instruction for direct payment from private and group health insurance companies to Marquette
Physical Therapy, P.A.
>> Fax Authorization Letter *
This is to give insurance companies and physicians authorization to fax Marquette Physical Therapy copies of your medical records.
>> Financial Policy *
This is a copy of our financial policy.
>> Outpatient Medical Records Release Form *
>> Cancellation Policy *
>> Medicare Cap **
The Medicare Cap form is used to show that you are aware and understand there is a cap on Medicare benefits.
>> One Time Medicare Authorization **
This form is used to authorize Marquette Physical Therapy to seek payment from Medicare.
>> Outpatient Notice of Privacy Practices
The forms listed on this page are for your reference. You can fill them out ahead of time if you wish, or you can fill them out at our office.
All patients must fill out forms marked with * prior to treatment.
Only Medicare patients must fill out forms marked with ** prior to treatment.
Click on the links below to download a PDF version of the form. Click here to get Adobe Reader.
>> Admittance Form *
This is the form that you will need to fill out for admittance.
>> Assignment of Benefits *
This form is for the assignment and instruction for direct payment from private and group health insurance companies to Marquette
Physical Therapy, P.A.
>> Fax Authorization Letter *
This is to give insurance companies and physicians authorization to fax Marquette Physical Therapy copies of your medical records.
>> Financial Policy *
This is a copy of our financial policy.
>> Outpatient Medical Records Release Form *
>> Cancellation Policy *
>> Medicare Cap **
The Medicare Cap form is used to show that you are aware and understand there is a cap on Medicare benefits.
>> One Time Medicare Authorization **
This form is used to authorize Marquette Physical Therapy to seek payment from Medicare.
>> Outpatient Notice of Privacy Practices
33255 Lexington Avenue, Suite A
DeSoto, KS 66018
Phone: 913-585-9844
Fax: 913-585-9841
DeSoto, KS 66018
Phone: 913-585-9844
Fax: 913-585-9841
6405 Metcalf Ave., Bldg 3, Suite 112
Overland Park, KS 66202
Phone: 913-484-7632
Fax: 913-403-8808
Get Directions
Overland Park, KS 66202
Phone: 913-484-7632
Fax: 913-403-8808
Get Directions
Two convenient locations providing Physical & Occupational Therapy
