Practice Location: 1634 Avenue of the Cities
Moline, Illinois 61265-4860
Phone : 563-940-2481
Fax     : 866-761-7464

First Physical Therapy Visit

Please print clearly in BLACK ink, thanks

Insurance – print off and complete the one that applies to you (see Health Insurance below for more info)

Other Forms

Attendance Policy

Your success in Physical Therapy is dependent on regular attendance. There is often a wait of 2 to 6 weeks for new patients to start therapy, and I often have a waiting list of patients needing treatment. Please provide 24 hour notice if you are unable to attend. This gives me time to call those on the cancellation list.

Failed appointments or those cancelled after 24 hours will be charged a $50 cancellation fee. Repeated failures to attend will result in re-evaluation of your need for therapy. Emergencies or weather cancellations will not be charged the cancellation fee.

Please note – Insurance will not pay for you to see two different Physical Therapists on the same day. If you are receive PT at another office (for a separate condition), please do not schedule two PT visits on the same day.

Please help me to provide the best care possible for you and others.

Health Insurance

Checking your insurance benefits
I am in network with most BCBS and Medicare policies.
Chicagoland Medical Billing Specialists (815- 986-4444) will check your benefits before or immediately after your first visit. The information needed for an insurance benefit check is on the New Patient information form. Make sure to bring a copy of New Patient information form and your insurance card to your first visit.
In order to check your insurance before your first visit I need you to either:

  • Fax the completed New Patient Information form to Chicagoland Medical Billing Specialists at 815-986-0796
  • Mail the completed New Patient Information form to Chicagoland Medical Billing Specialist 5301 E. State St, Suite 117 Rockford, IL 61108. Please allow 7 to 10 business days before your appointment
  • Call Chicagoland Medical Billing Specialists 815-986-4444 to provide the required information
  • Results of the insurance benefit check will be available from Beth at your first visit

Disclaimer: This check of insurance is not a guarantee of payment. Your insurance company could have omitted important information, or misquoted benefit information. You should double check your benefits either by reading your policy or by contacting your insurance directly.

Information needed in order to check your own benefits

  • Beth Shelly Physical Therapy LLC tax ID number 83-2117985.
  • Beth Shelly Physical Therapy LLC Billing NPI 1962973073.
  • I bill physical therapy as an office visit.

At this time I am out of network with United and Tricare – please see "Self-pay"
Email Beth Beth@bethshelly.com or call 563-940-2481

Don’t let anything get in the way of your success in physical therapy – you are worth it - achieve great health now.

At this time I am unable to process claims for the following Medicare and Medicare replacement plans:

  • Medicare Railroad
  • United Medicare HMO (I am in network with United Medicare PPO)
  • GEHA
  • Healthlink
  • Health Alliance
  • Cigna
  • Aetna Medicare
  • Medicaid
  • Humana
  • VACAA Veteran’s choice
Your physician and I will work together to find you a physical therapist who can provide the therapy you require. Email Beth Beth@bethshelly.com or call 563-940-2481