Initial Patient Questionnaire printable pdf download

Initial Patient Questionnaire

INITIAL PATIENT QUESTIONNAIRE

Patient’s Name_________________________________________ SS#_________________________

Insured Name__________________________________________ SS#_________________________

Insurance Company_________________________________ Date of Injury_______________________

Insurance Phone #__________________________________Group/Policy #_______________________

Claim or Case #______________________________________________________________________

Referring Physician Name______________________________________________________________

Address____________________________________________________________________________

Physician’s Phone #__________________________________________________________________

Diagnoses Number(s)_________________________________________________________________

____________________________________________________________________________________

Office Use Only

Insurance Company__________________________________________________________________

Attn: (Insurance Adjustor, Team #, etc)___________________________________________________

Mailing Address_____________________________________________________________________

Phone #__________________________________ Fax #_____________________________________

Are benefits exhausted? Yes

Has deductible been met? Yes

What percentage does insurance cover?_______%

/ 5030 S Hwy 17-92 / Suite B / Casselberry, FL 32707 / 407.332.6842

Initial Patient Questionnaire