New Patient Registration Forms

New Patient Registration Forms

Any new patients registering in the Hartford HealthCare Rehabilitation Network are required to complete the forms located below. To download the forms, please click the blue download button to the right of your required forms. Please be sure to bring your completed forms with your insurance card(s) as well as any referral forms from your physician.

Backus Hospital Rehabilitation Network

Central Connecticut Senior Health Services

Hartford Hospital Rehabilitation Network

Assignment and Authorization

Required Form

Download

Asignación y Authorización

Required Form

Download

Patient Information Restriction Form

Required Form

Download

Formulario de Restriccion de Informacion del Paciente

Required Form

Download

Medical History Form

Required Form

Download

Formulario de Historial Médico

Required Form

Download

Medical History Onocology Form

Complete if applicable

Download

Authorization to Disclose / Obtain Health Information

Complete if applicable

Download

Autorización Para Divulgar / Obtener Información de Salud

Complete if applicable

Download

The Hospital of Central Connecticut Rehabilitation Network

Arm Shoulder Hand Quick DASH

Download

Back Pain Oswestry

Download

Back Pain Oswestry Spanish

Download

Breast Cancer

Download

General Functional Scale

Download

General Functional Scale Spanish

Download

Lower Extremity Functional Scale

Download

Neck Disability Index

Download

Past Medical History Form

Download

Formulario de Historial Médico

Download

Past Medical History Form Polish

Download

Speech-General

Download

Vestibular Dizziness Handicap Index

Download

Windham Hospital Rehabilitation Network

Assignment & Authorization

Required Form

Download

Patient Information Restriction Form

Required Form

Download

Medical Release Form

Required Form

Download

New Patient Registration