| Referral Form and Map |
New Patients: thank you for printing out and completing the forms in our New Patient Packet below. Please bring, mail, or fax them to our office. Please include a clear image, front and back, of your insurance card(s) and driver's license. To find our office, please see detailed directions above: click the "FIND US" tab.
(Please quickly complete and submit your forms so our data entry specialist can get your chart ready before scheduling your 1st appointment. This way, the PT will have more information at hand in order to more helpfully and specifically answer your questions on or before your first visit).
If you have any questions regarding paperwork, please call 530-891-4456. You can communicate with us via email at office@simplyresultspt.com.
If you need a packet sent to you, through the regular mail, please leave a message with your address at 530-891-4456.
If you need a packet sent to you, through the regular mail, please leave a message with your address at 530-891-4456.
| New Patient Intake Forms |
FOR YOUR FIRST APPOINTMENT: Please remember to wear your face mask, and make sure it covers both your mouth and your nose for the entirety of your visit. For the safety of all in our care, we request all patients with in-office visits be fully vaccinated against COVID-19. We're requesting that all patients bring their COVID-19 Vaccination Record Card to their appointment, so that we may have a copy in our records. If you are not vaccinated, sometimes the PT can still do your visit, depending on the situation. Please ask.
WE ARE IN-NETWORK MEDICARE PROVIDERS: Courtesy billing provided.
If you have coverage that is not Medicare, please call your insurance plan representatives in order to verify your benefits for physical therapy. We are also in-network with Blue Shield employer plans and TRICARE (formerly known as CHAMPUS)/TriWest/CCN for VA Members.
Co-pay and deductible are due on day of service.
All credit cards accepted. We offer to people paying out-of-network a 5% discount for check or cash on the day of care.
If you believe your insurance is out of network, please feel free to use this benefits questionnaire form as a guide while talking to your insurance representative. Some insurance companies may provide coverage through Blue Shield, and some insurance plans may offer reimbursement for out of network care.
WE ARE IN-NETWORK MEDICARE PROVIDERS: Courtesy billing provided.
If you have coverage that is not Medicare, please call your insurance plan representatives in order to verify your benefits for physical therapy. We are also in-network with Blue Shield employer plans and TRICARE (formerly known as CHAMPUS)/TriWest/CCN for VA Members.
Co-pay and deductible are due on day of service.
All credit cards accepted. We offer to people paying out-of-network a 5% discount for check or cash on the day of care.
If you believe your insurance is out of network, please feel free to use this benefits questionnaire form as a guide while talking to your insurance representative. Some insurance companies may provide coverage through Blue Shield, and some insurance plans may offer reimbursement for out of network care.
| Patient Benefits Questionnaire |
