



| Midwest Physical Therapy & Rehab | Riaz Khan, PT, DPT | 513 Fourth Avenue Rochelle, IL 61068 www.Midwest-PhysicalTherapy.com | Site By: www.GoRochelle.com All Rights Reserved |
| 513 Fourth Avenue Rochelle, IL 61068 Phone: 815-561-8786 FAX: 815-986-8943 www.Midwest-PhysicalTherapy.com |

| Accept: Medicare, Blue Cross, ECOH Multiplan, FirstHealth, Cigna, OSF, ect... Same Day Appointment if needed |
| Forms Assignment of Benefits | Job Requirements Lower Back Questionaire | Neck Disability Index | Privacy Policies Shoulder Pain | Patient Registration To save time please complete forms and bring to our office. |