Download & Print Your Physical Therapy TREATMENT Forms

Bring them with you on your first visit or scan and send them back to us before your first session.

PHYSICAL THERAPY PATIENTS (Receiving Treatment by a licensed physical therapist)
1.  General Intake/HIPAA/Release
2.  Informed Consent/Direct Access
3.  COVID19 Vaccination Info & Informed Consent
4.  Telehealth Policies & Procedures (In the event we do video sessions)


The following forms may be needed for specific purposes and you'll be instructed if you need to fill any of these out. 

*  HIPAA authorization to disclose Personal Health Information Form - enables us to share your specified personal health information with a person outside of ProBalance or your referring physician.

Physical Therapy FAQ's

Do I need a prescription to see a physical therapist?

In the state of CA, you may go directly to a physical therapist for up to 12 visits or 45 days (whichever comes first), before seeing a physician or chiropractor for physical therapy treatment of an injury or specific condition. However, if it appears that you need care that is beyond the scope of physical therapy, we will refer you out to the appropriate practitioner at that time to get a medical diagnosis.  Some insurance companies insurance companies require a diagnosis code to receive reimbursement so you may still want to see your MD or DC prior to starting PT if you are planning on submitting to your insurance.

What if I want to see a physical therapist for wellness services?

Often, clients are looking for a safe, efficient way to improve their overall wellness, fitness, and function but may have pre-existing health conditions that would make it wise to first be screened and initially perform these types of fitness activities with a physical therapist. All of the physical therapists who work out of our office are specialists in recognizing abnormal movement patterns, muscle imbalances, soft tissue/joint restrictions, postural dysfunction, etc. throughout the body.

In our “Wellness PT/Pilates sessions”, physical therapists are able to use the skills within their scope of practice to improve and optimize movement without a specific diagnosis. Note that these Wellness PT/Pilates sessions are not covered by insurance or Medicare.

Does ProBalance bill insurance for Physical Therapy services?

Many of the services at ProBalance may be reimbursed by your insurance. Please note that to maintain our high standard of care, we are not contracted with health insurance providers and are therefore considered an out of network provider. Although we are out of network, our physical therapy services may still be covered by your insurance, but it is your responsibility to understand the limitations of your insurance with regards to deductibles and copays so there are no surprises when you receive payment.

Payment to ProBalance is expected at the time of service, and upon request, we will provide you with a super-bill, which contains the codes required for reimbursement directly from your insurance.  It is recommended that you submit your first super-bill as soon as possible to ensure that there are no surprises from your insurance company.  We're sorry, but we do not do courtesy submissions to your insurance at this time.

Are physical therapy services covered by FlexSpend or Health Savings Accounts (HSA)?

Physical therapy and Pilates services for rehabilitation are typically reimbursable by FlexSpend or HSA plans, if instructed by a physical therapist, as it is a form of therapeutic exercise, neuromuscular re-educaiton, and functional re-training. A prescription for Pilates (if paying for wellness/fitness Pilates) from your MD or DC is recommended to ensure that the interventions are medically necessary.

Do you accept Medicare?

ProBalance is not enrolled as a Medicare provider and therefore we are not set up to bill Medicare for PT services. If you do have Medicare PT benefits and a prescription for physical therapy, we will refer you to a different clinic so you are able to take advantage of your Medicare benefits for treatment of your specific diagnosis.

We will be happy to see Medicare eligible clients for non-covered “Wellness PT/Pilates” concurrent with your PT treatment at a different facility or after your Medicare benefits have been exhausted.  Please let us know if you are a Medicare beneficiary so we can advise you appropriately.

Does ProBalance take liens or bill third party payors?

If you were involved in an automobile accident or personal injury case that was not your fault, you may still need medical attention and treatment while waiting for a settlement from the other party to pay back your medical providers. Unfortunately, our office is not set up for being able to handle liens or to bill your auto insurance med-pay directly. You may still utilize our services if you choose to pay at the time of service and submit the superbill with Physical Therapy treatment codes to the auto insurance company on your own.

I have a prescription for physical therapy on another facility’s stationary. Do I need a specific referral to use ProBalance for PT?

You are not restricted to seeing a particular therapist based on the stationary that the physical therapy referral was written on. As long as your referral requests physical therapy, it can be honored at any facility.

What is the treatment philosophy/approach at ProBalance PT?

You might think that that your pain is due to something structural that needs to be massaged, manipulated, or stretched to feel better.  In some cases, this is true.  More often, it is how you move (aka your movement strategy) that matters more than you realize.  Faulty movement strategies can be a source of structural problems that either cause injury or delay healing. You can manipulate a structure, but if you don't teach the body what to do with that new motion, it'll often return to its original dysfunctional state.

Using a proactive approach, our physical therapists identify and correct faulty motor patterns using Pilates based exercise. Structural restrictions affecting movement quality are targeted using skilled manual therapy techniques and/or other interventions such as myofascial decompression (aka cupping), when needed.  Most importantly, you are taught how to manage and prevent injuries by more deeply understanding the relationships within the body.

FREE Resources

Understanding WHY you are doing something helps you become an integral part of your own healing.   Click below for some of our free resources listed inside our Online "Be Well-Stay Well™" portal, including simple exercises, mini-workouts, mythbusting videos, a posture & body mechanics checklist, and more.

Click here