New Patients

Patient Forms

Please use black ink on all 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.

I am in network with most BCBS and Medicare policies.

Health Insurance

Does Insurance Pay for Pelvic Physical Therapy?

Pelvic PT is covered the same as any type of PT, and coverage depends on the specifics of your insurance plan. To learn more, click here.

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.

Please note there will be a $3.00 card processing fee beginning July 1. 2024.

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.


Print off and complete the one that applies to you.

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

Medicare and Medicare Replacement

  • Medicare Railroad
  • Aetna, United, Humana Medicare HMO
  • BCBS Medicare – Medicaid alignment initiative
  • Medicaid secondary to Medicare

Your physician and I will work together to find you a physical therapist who can provide the therapy you require.

Standard Insurance

  • United
  • Cigna State of IL
  • Medicaid
  • All VA, Tricare, TriWest

At this time I am out of network with these insurance companies. The most cost effective plan is “Self-Pay

Email Beth or call 563-940-2481 to discuss your options for quality specialized physical therapy.

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

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