Insurance and Forms

PediaFlex Forms


We encourage you to print and fill out the following forms prior to your initial appointment at PediaFlex.  Please remember to print and have your pediatrician or specialist fill out the medical prescription form prior to your appointment.  If you are unable to fill out the other forms before your appointment, please plan on arriving at least 15 minutes early to complete them.

Medical Prescription for Physical Therapy (Fax Ready)

Patient and Family Information and Contact Form

Pediatric History Form

Notice of Privacy Practices

Driving Directions


Payment for Services and Health Insurance Information


We are an "Out-of-Network" physical therapy practice.

Payment will be due at the time of service.  For your convenience, we accept payment of cash, check, or credit/debit card. 

It is important that you understand and determine your individual health plan’s out-of-network PT benefits.  To learn more about your coverage, please call the member services number on your insurance card.  When you’re speaking to the member services representative, you will want to determine the information that we have summarized in the form linked below.

Out-of-Network Claim Information Guide

We will be providing you with a “Claim Submission Packet” as required by the insurance company for claim submission.  This packet will include:  an itemized bill, sometimes referred to as a Superbill with all necessary coding information regarding the services provided; a copy of your doctor’s prescription for PT; and supporting clinical documentation as required by your insurance company.  This information will need to be forwarded by you to your insurance company for claim submission and reimbursement.