Patient & Visitors Guide: Outpatient Forms
Good Shepherd offers outpatient rehabilitation at numerous sites throughout eastern Pennsylvania. When you arrive for your first appointment at one of Good Shepherd's outpatient rehabilitation locations, you will be asked to complete paperwork relating to your medical information and privacy.
You can save time by printing and completing this paperwork BEFORE you arrive for your initial appointment.
Click on the documents below to download the appropriate forms. Then, fill out the forms and bring them with you to your first outpatient appointment.
Acknowledgement of Receipt of Notices of Rights, Visitation and Privacy Practices [2]
Request for Restriction of Health Information/Visitor Restrictions [3]
Conditions of Services Provided by Good Shepherd Medicare Rights & Responsibilities [4]
Medicare Secondary Payer Form [5]
Outpatient Rehabilitation Patient Medical Information Sheet [6]
Outpatient Rehabilitation Patient Medical Information Sheet (Spanish [7])
Pediatric Specialty Forms
Pediatric Feeding Program Intake Form [8]
Pediatric Augmentative and Alternative Communication Intake Form [9]
NOTE: These forms are only necessary for patients at one of Good Shepherd's outpatient rehabilitation locations. Click here for a list of Good Shepherd's outpatient sites [10].
For more information on Good Shepherd Rehabilitation Network, contact us [11], call 1-888-44-REHAB (73422) or Request an Appointment [12].
