Patient Forms

Veterans Administration-referred patient forms redirect here.

All forms are in Adobe Acrobat PDF format and will require that you have that software. Please bring the completed forms with you to your first visit. Alternatively, you may complete these forms when you arrive at the clinic for your initial visit. All required forms must be completed before your session begins.

You can save your completed forms and email them to admin@mbmyoskeletal.com. However, this method is NOT recommended because email is not a secure medium and is NOT HIPAA compliant. Your information, once in our hands, will be kept strictly confidential.

Please read all forms carefully before signing.

New Patients: Please use the links below to download and complete MBM Policies, Patient Health History, and Informed Consent for either Adult or Minors as appropriate.

If you wish us to file insurance claims on your behalf, please follow the instructions for Insurance Claim Information and Financial Agreement forms below. We are NOT able to file claims with Medicare, Medicaid, or Part B or C Medicare Advantage programs.

Returning Patients: No forms are necessary if your last visit was within the past 6 months.  If your last visit was more than 1 year ago or if any of your information has changed, please complete Patient Health History form again.

If you want Manchester-Bedford Myoskeletal LLC to release any portion of your clinic records or if you want us to obtain any medical information from another provider (imaging, diagnosis, records, etc.) for review in this office: Please complete Medical Records Release Form.  Please understand that no confidential information will be released to anyone without this completed form unless another provider sends their own release form with your signature to us.

MBM Policies – Please print, read, sign, and date.

Patient Health History – Please print this form, fill out both sides completely, sign, and date.

Adult Informed Consent – Please print this form, read, sign, and date.

Medical Records Release – Please complete this form if you want us to release any portion of your file to your designee or if you want us to obtain any portion of your medical records from another provider’s office.

Minor Informed Consent – Please complete this form if patient is a minor.

Insurance Claim Information – If you wish us to file claims with your health insurance company, please print this form and ask your physician’s office for this information or ask them to fill it out for you and bring it with you to your appointment here. No signature is required. If your physician’s office declines to provide the information, your claim may be denied by your insurance company. We are NOT able to file claims with Medicare, Medicaid, or Part B Medicare Supplemental or Part C Medicare Advantage programs.

Financial Agreement – If you wish us to file claims on your behalf to your health insurance company, please print, read, & complete the appropriate sections, sign, and date.

Click here to view our Notices of Privacy Practices. You may print a copy for your records. You may obtain a copy from our office upon request. The law does not require us to comply with HIPAA laws or regulations. However, we take our confidential relationship with our patients seriously and endeavor to comply as closely as practicable.