APPLICATION FOR PHYSICAL THERAPY

PT Over MS®, LLC provides payment for a limited number of physical therapy sessions to a limited number of people living with MS in the northern Illinois area. If you are interested, please complete the attached 5 page application. Also, you will need the following two other papers:

ASK YOUR DOCTOR:

You will need:

  1. A prescription for the standard number of physical treatment MS therapy treatments.
  2. A short note from your doctor stating his/her belief, that you have MS.

TAKE THE NEXT STEP:

Please attach the prescription and your doctor’s note to your completed application. To start the process, this is all you need!

MAIL TO:

PT Over MS®, LLC

PO Box 6116
Lindenhurst, IL 60046

Or FAX: (847) 623-6406
Or E-mail: [email protected]

Please be patient with us, we might need 4 weeks to get back to you.

WHAT ELSE IS NEEDED:

You need approval from the Board of PT Over MS®, LLC to proceed. Approval will come back to you by letter. Once you get your full approval, you will be asked to set up your own appointments. You are responsible for your own transportation.
Our preferred physical therapy facilities are Praxis in Vernon Hills, IL. and Good Shepard Hospital in Barrington, IL. Should you have a favorite facility that you are comfortable with, we will seriously consider it.


THE APPLICANT’S DOCTOR:

His/Her name:
His/Her phone:
His/Her address:

APPLICANT’S INFORMATION:

Name:
Last 4 digits of your Social Security #
Your DOB:
Married: Yes No

Children living at home:
Ages:
Current Address:
How long?:
Is this the address you want us to use for you? Yes No

Phone number that you want us to reach you:
When is the best time to call?
E mail address:

APPLICANT’S INSURANCE:

Company name:
Policy Number or Group Number:
Does your insurance cover physical therapy? Yes No

FINANCIAL INFORMATION:

Do you feel that you would qualify for financial aid? Yes No

Would you be willing to submit your last 3 years tax returns supporting your need for financial aid? Yes No

YOU, THE APPLICANT:

Please tell us something about yourself.
How long ago did you get your MS diagnosis?
Please tell us how you felt when you first learned about your MS diagnosis?
After dealing with your MS for some time, please tell us how you feel about it now.
Are you taking any medications for your MS? Yes No

Which one(s)?
Your mobility is very important to everyday life. Please tell us about your mobility.
To what extent does the MS limit your mobility? (Example: no limitations, some difficulty walking, walk with canes or walker, wheel chair assist, use scooter ...or anything that you would like to share with us.)
Is your mobility getting progressively more difficult to keep up?
Do you have any additional comments regarding your current mobility? Yes No


In spite of the MS, what are you doing to maintain your mobility and activity?
Do you have an in home personal work-out or PT routine? Yes No

Have you ever had physical therapy? Yes No

Please tell us something about it.
Do you have a favorite or preferred physical therapy facility?
Do you find the use of a wheelchair or scooter convenient and helpful? Yes No

How often do you use your wheelchair or scooter?
In your opinion, with your level of health, is there more that you could be doing to help yourself? Yes No

If there is more that you could be doing, please tell us something about it.
Tell us some of your favorite pastime activities that you still like and are able to do.
Tell us why you are applying for this grant to pay for physical therapy?
Is there anything else that you would like to tell us?

SIGNATURE:

As part of your application and by signing the application, you agree to hold PT Over MS®, LLC, its Board of Directors, employees, and any and all its affiliates, harmless for any and all liabilities arising from treatment by any medical provider or from any activity of PT Over MS®, LLC.

Signature:
Date:

Please give us about 4 weeks to respond to your application. We will respond to you no matter what the outcome.

For additional questions, please call (847) 623-6886 or email to: [email protected]


Thank you,

Henry Athabasca

Founder / Manager