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at Home

Safe, personalized outpatient physical therapy delivered in the comfort of home.

✚

Medicare Part B accepted

🏠

Therapy in the comfort of home

👥

Designed for older adults

♡

Family & caregiver friendly

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Patient Information

Patient Full Name *

Date of Birth *

Phone Number *

Email Address

Preferred Method of ContactCallTextEmail

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Insurance Information

Primary Insurance Provider

Member ID

Do you have a secondary insurance?YesNoNot Sure

Secondary Insurance Provider

Member ID

Do you have Medicare Part B?YesNoNot Sure

Therapy Services Requested

Balance / Fall Prevention

Post-surgical rehab

Strength

Gait / Posture

Endurance

Mobility

Neurological

Pain

Other

If other, please explain

Background Information

Have you had home health therapy in the last 60 days?YesNoNot Sure

What are your goals?

Anything else we need to know?

Consent *

I understand this form is not for emergencies AND Continuity Healthcare Services may contact me about therapy services.

What Happens Next?

We make the process simple.

Submit your request

Our team reviews your information

We contact you within 1 business day

We coordinate with your physician & insurance

Outpatient physical therapy delivered at home for older adults.

Start Therapy at Home

Quick Links

Therapists Our Mission About Us Patient Education

Phone913-318-5104

Fax888-506-5780

Emailinfo@continuityhs.com

Trusted. Compassionate. Consistent.
Therapy that helps you thrive—at home.