We are required to report to Medicare that we have documented this information as part of your physical therapy care.
Per specic Medicare reporting rules, we need you to “provide a list of all known prescriptions, over-the-counter medications,
herbal supplements, and vitamin/mineral/dietary supplements. This list must contain the medications’ name, dosage, frequency and route
of administration.
As a Medicare-insured patient, please provide the following information:
Patient Printed Name ______________________________________________
Patient Signature _________________________________________________Date ___________________________________
*You may be asked to update this information at a future appointment. If this is the case, we will provide the original form for your
reference and ask for your patience and cooperation in providing any additional information.
We appreciate having you as our patient and will do our best to provide any needed assistance. Thank You!
Patient Statement of Updated Medications Listing (For Future Use Only, If Required)
My medications listing is current and/or has been updated at the Physical Therapy Re-Evaluation Appointment, as indicated.
Patient Signature _________________________________________________Date Updated ___________________________
Medicare Supplemental Forms | Current Medications
Please fill out this form completely. Thank You!
Medication Name
(Prescriptions, Over The Counter, Supplements)
How Much?
How Often?
How Do You Take It?
(Route of Administration)
Example: Tylenol 300mg 2x/day Pills/Oral
If you need more space, were happy to provide additional forms – just let us know.
There are items and services for which Medicare will not pay.
Notice of Exclusions from Medicare Benets (NEMB)
• Medicare does not pay for all of your health care costs. Medicare only pays for covered benefits.
Some items and services are not Medicare benets and Medicare will not pay for them.
When you receive an item or service that is not a Medicare benefit, you are responsible to pay for it, personally or through
any other insurance that you may have.
The purpose of this notice is to help you make an informed choice about whether or not you want to receive these items or
services, knowing that you will have to pay for them yourself.
Before you make a decision, you should read this entire notice carefully.
• Ask us to explain, if you don’t understand why Medicare won’t pay.
• Ask us how much these items or services will cost you (Estimated Cost: N/A ).
Patient Signature
* This is only a general summary of exclusions from Medicare benefits. It is not a legal document. The official Medicare program
provisions are contained in relevant laws, regulations, and rulings.
Patient Signature _________________________________________________Date ___________________________________
Patient Printed Name ______________________________________________
Medicare will not pay for:
Physical Therapy and Speech Language Pathology services over $2,110.00 in
2021. **You may receive covered services through a hospital outpatient therapy department.
1. Because it does not meet the denition of any Medicare benet
2. Because of the following exclusion * from Medicare benets:
Personal comfort items
Most shots (vaccinations)
Hearing aids and hearing examinations
Most outpatient prescription drugs
Orthopedic shoes and foot supports (orthotics)
Health care received outside of the USA
Services required as a result of war
Services paid for by a governmental entity that is not Medicare
Services for which the patient has no legal obligation to pay
Home health services furnished under a plan of care, if the agency does not submit the claim
Items and services excluded under the Assisted Suicide Funding Restriction Act of 1997
Items or services furnished in a competitive acquisition area by any entity that does not have a contract with the Department of
Health and Human Services (except in a case of urgent need)
Physicians’ services performed by a physician assistant, midwife, psychologist, or nurse anesthetist, when furnished to an inpatient,
unless they are furnished under arrangements by the hospital
Items and services furnished to an individual who is a resident of a skilled nursing facility (a SNF) or of a part of a facility that
includes a SNF, unless they are furnished under arrangements by the SNF
Services of an assistant at surgery without prior approval from the peer review organization
Outpatient occupational and physical therapy services furnished incident to a physicians services
Routine physicals and most tests for screening
Routine eye care, eyeglasses and examinations
Cosmetic surgery
Dental care and dentures (in most cases)
Routine foot care and flat foot care
Services by immediate relatives
Services under a physicians private contract
Medicare Supplemental Forms | Exclusion(s) from Covered Benets
Please fill out this form completely. Thank You!