We accept most PPO Plans: Anthem Blue Cross, Aetna, Health Net, United Health Care, Blue Shield, Cigna, Operating Engineers, Pacific Care. We also accept Medicare, Workers Compensation, and Personal Injuries

How To Fill Out Your Paperwork

Our main focus at Irvine Physical Medicine & Rehabilitation is the health and well being of our patients. Keeping this in mind we have made it possible to print and fill out paperwork from the convenience of your home or office. This enables our patients to receive care almost immediately upon arrival. You can submit your paperwork in person or by fax 949.552.9393 prior to your scheduled appointment.

We have three sets of paperwork categorized by insurance type. If you are a new patient you must print and fill out the entire set of forms under the insurance category in which you pertain by clicking the (Print All) option at the end of the individual category. If you are a returning patient you can choose to print an individual form by clicking on the form name.

Please read, complete and sign each form. If you need assistance or have any questions please don’t hesitate to call our front office at 949.552.9393 (Monday thru Friday from 8:30 a.m. to 5:00 p.m.).

You must have Adobe Acrobat to view and print these documents. You can download Adobe Acrobat by clicking here

*INSURANCE COVERAGE, BENEFITS AND LIMITATIONS ARE THE SOLE RESPONSIBILITY OF THE PATIENT. IPMR WILL VERIFY YOUR INSURANCE BENEFITS AS A ONE TIME COURTESY AFTER YOUR FIRST VISIT.*

Preferred Provider Organization
A PPO applies to Doctors or Providers contracted with your insurance company to obtain the highest degree of benefits. For a list of insurance companies whom we are contracted with click here

PPO Forms
Patient Information
History Form
Assignment of Benefits
Privacy Practice (2 parts)

Workers Compensation
Workers Compensation applies to those individuals who have incurred a work related injury which has been reported to the Employer Human Resource Department. The injured employee must receive authorization from employers Worker Compensation Insurance Company to visit an assigned Physician. For more information please contact us or visit our FAQ section.

Workers Comp Forms
WC Patient Information Form
History Form
Assignment of Benefits
Privacy Practice (2 parts)

Personal Injury Patient Forms
Any injury resulting in an auto accident which has been reported to their auto insurance or personal injury in which an attorney has been retained.

Personal Injury Patient Forms
Patient Information
History
Assignment of Benefits
Privacy Practice (2 parts)
PI Lien