Cost coverage application form
Medical prescription for rehabilitation sports / functional training
Recommended sport
gymnastics
boolean
swimming
boolean
athletics
boolean
movement games
boolean
other sport
text
Self-confidence enhancement
boolean
Rehabilitation sports indication
50 workout
boolean
120 workouts if indicated
boolean
rehabilitation sport indication
integer
28 workouts for self-confidence enhancement
boolean
other workout volume
integer
120 workouts
boolean
Recommended functional sports
Functional sports indication
12 months of training
boolean
24 months of training
boolean
impairment as indication for functional training
integer
24 months training
boolean
other indications for rehabilitation sports
text
Rehabilitation sports
rehabilitation sport
integer
other workout volume
integer
Recommended workout frequency for rehabilitation sports/functional training
text
justification
text
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Cost Coverage application
service provider
text
rehabilitation sport since
date
Signature date
date
Cost Coverage declaration
rehabilitation sports
boolean
rehabilitation sports volume
integer
other rehabilitation sport volume
integer
Functional training
boolean
functional training volume
integer
functional training duration
integer
other functional training duration
integer
physical therapy start date
date
physical therapy end date
date
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