Pre-Register | Aquatic Therapy

Step 1

Complete the following information and provide it to us via email (atwtherapy@yahoo.com) or by phone (815-893-0439) so insurance coverage can be verified prior to your first visit. You will receive a phone call detailing what your insurance will pay for services.
CASH clients may skip to STEP 2.

Name*
First Last
Date of Birth*
Month
Day
Year
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Primary Insurance Company*
Primary Insurance ID*
Primary Insurance Policy #*
Secondary Insurance Company*
Secondary Insurance ID*
Secondary Insurance Policy #*

Step 2

2021 Patient Registration and HIPAA Forms (PDF)

Download

ATW and Patient Accountability Form (PDF)

Download

ATW Privacy Policy (PDF)

Download

Step 3

Bring the completed and signed forms with you on your first visit. We also appreciate any pertinent medical records, X-rays, and MRI’s you may have. Also bring a list of your current medications.