Patient Information

Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
SEX*
- Male
- Female
YOUR SOCIAL SECURITY #*
Home Address*
APT#*
CITY*
STATE*
ZIP*
HOME TELEPHONE*
WORK TELEPHONE*
EMERGENCY CONTACT*
TEL#*
DATE OF INJURY*
Date Format: MM slash DD slash YYYY
PRIMARY INSURANCE COMPANY: (WHO DO WE BILL)*
YOUR POLICY #*
CLAIM #*
POLICY HOLDER (IF NOT YOU)*
First Last
LIST ALL SECONDARY INSURANCES*
WORKERS COMP. ONLY. PLEASE LIST THE FOLLOWING:
EMPLOYERS NAME*
EMPLOYER ADDRESS*
TEL#*
INS CO. NAME*
INS CO. ADDRESS*
TEL#*
WCB CASE#*
WCB CASE#*
CARRIER CASE #*
INITIAL VISIT: $RATE

ALL FOLLOW-UPS: $RATE

NOTE: MANY INS. CARRIERS NOW REQUEST BILLING BY PROCEDURE CODE EACH CODE: $RATE

ALL PATIENTS ARE PERSONALLY RESPONSIBLE FOR FULL PAYMENT OF ALL CHARGES INCLUDING INSURANCE COMPANY DENIALS, DEDUCTIBLES AND COPAYMENT FEES. CANCELLATIONS SHOULD BE MADE 24 HOURS IN ADVANCE.

NOTICE OF ADVICE: THE TREATMENT MAY NOT BE COVERED BY THE PATIENT’S HEALTH CARE PLAN OR INSURER WITHOUT A REFERRAL AND THAT SUCH TREATMENT MAY BE A COVERED EXPENSE IF RENDERED PURSUANT TO A REFERRAL
Consent
I, THE UNDERSIGNED, AGREE TO BE TREATED IN THIS THERAPY OFFICE AND HEREBY AUTHORIZE MY INSURANCE CARRIER TO PAY THE PROVIDER DIRECTLY FOR SERVICES RENDERED. I HAVE READ THE ABOVE AND AGREE TO COMPLY FULLY, SIGNED:
Signature
TODAYS DATE*
Date Format: MM slash DD slash YYYY
HOW DID YOU FIND OUT FACILITY*
THE TREATING THERAPIST'S SIGNITURE*