Hamilton Physical Therapy Services, Lp Patient Intake And Consent Form printable pdf download

HAMILTON PHYSICAL THERAPY SERVICES, LP

PATIENT INTAKE AND CONSENT FORM

ACCOUNT #_________________________________ACCOUNT TYPE__________________________

First Name ______________________________ MI______ Date of injury/Onset___________________

Last Name ____________________________ Date of Birth_____________________ Age ___________

Address __________________________________ Sex M F

Marital Status S M D W

City ____________________________

St____

Zip __________

SS # ___________________

Phone: H_________________Wk_______________Cell_________________E-Mail_________________

Injury Area ______________________________________

Accident Related: Yes

If Accident: Auto

Work Other

Nature of Accident __________________________________

Claim Filed: Yes No

PIP Filed: Yes No

Presently Working? Yes No

Restricted Duty

Employer _____________________________________________________________________________

Address __________________________________ City ____________________ St _____ Zip_________

Contact Person @ Work: ________________________________________________________________

Occupation: ___________________________________________________________________________

Referring Physician __________________________________

Phone #_______________________

Primary Physician ___________________________________

Phone # _______________________

EMERGENCY CONTACT ___________________________

Phone # _______________________

Primary Ins. ____________________________________ Subscriber ID# _________________________

Billing Address: _________________________________________ Phone # ______________________

Subscriber’s Name:__________________________________________ D.O.B.____________________

Patient Relation to Insured: Self, Spouse, Child, Other

Deductible/Copay: ________________

Verification/Comments: _________________________________________________________________

____________________________________________________Verified by: _______________________

Secondary Ins. _________________________________ Subscriber’s ID#__________________________

Billing Address: _________________________________________Phone#: ________________________

Subscriber’s Name: ______________________________________ Subscriber’s DOB: ______________

Patient Relation to Insured: Self, Spouse, Child, Other

Deductible/Copay: ________________

Verification Comments: _________________________________________________________________

Insurance verification is not a guarantee of payment or accuracy of benefits. Please call your member

services directly for physical therapy benefits.

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Hamilton Physical Therapy Services, Lp Patient Intake And Consent Form

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