GENERAL INFORMATION

DATE:

Last Name:

First Name:

Sex :M F D.O.B://

Address:

City: State:

Zip Code:

Home #:

Work #:

Cell. #:

Email:

Status: Single Married

INSURANCE INFORMATION

Primary
Insured:

D.O.B: //

Insurance
Name:

ID/Subscriber #:

Group #:

Do you have any other insurance?
(IF YES PLEASE COMPLETE BELOW)
YES NO
Insured’s Name:

D.O.B.://

Insurance Name:

ID #:

Group #:

EMERGENCY CONTACT

Name:

Relationship to Patient:

Home #:

Work #:

Cell. #:

Other Information
Please circle one.
1. Was this injury cause by an accident?  Y / N

1b.If yes, was it due to work/ auto/ other? Explain.

2. Have you had physical therapy for this condition this year? Y / N

2b. When? Where?

Medical Services Agreement

You acknowledge that it is your responsibility to:

1. Provide complete up-to-date information on medical insurance for the patient.

2. Present a valid insurance card and notify the corporation of any changes, whether it be insurance change or plan changes within the same insurance.

3. Pay any co-payment, and/or non covered services at the time of service and meet any applicable deductible, unless a separate agreement has been made with the corporation.

4. You are to cancel your appointment 24-hours prior to your scheduled appointment, unless otherwise agreement, you will be responsible for a cancellation fee of $60.00.

IN THE EVENT THAT YOU DO NOT HAVE MEDICAL INSURANCE OR WE DO NOT PARTICIPATE IN YOUR PLAN, PAYMENT IS EXPECTED IN FULL AT THE TIME OF THE SERVICE.

Your signature below indicates that you understand and accept our policy of assignment of insurance benefits, attest to the accuracy and completeness of the medical insurance information, authorize this office to release medical information necessary to process your claims and appeals, and authorize payment of medical benefits to our corporation (all doctors included).

PATIENT’S SIGNATURE
(If patient is under 18 yrs Parent/ Guardian must sign and are considered the responsible party)

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