No Fault Patient Form printable pdf download

NO-FAULT PATIENTS

Patients Name: ___________________________________________________

No-Fault Insurance Company: ________________________________________

No-Fault Address:

_________________________________________

_______________________________________

No-Fault Phone Number: (

) _______________________________________

Claim Number: ___________________________________________

Policy Number: ___________________________________________

Date of Accident: _________________________________________

Policy Holders Name: ______________________________________

We at ProActive Sports Rehab will be more than happy to bill your No-Fault carrier. If

we receive a denial from your No-Fault carrier we will bill your private insurance, if

provided to us. We recommend that you provide us with your private insurance

information from the start of your physical therapy. Some private insurances do require

prior authorization. In the event you did not give us your private insurance and your

No-Fault claims are denied, most private carriers will not back date the authorization

from the start of your No-Fault denial. Then the patient would be responsible for the

claims. Also, some referrals need to be done by your primary care physician. Please

check with your member services department to see if you one is required for physical

therapy.

If your No-Fault is denied, not only is the patient responsible for getting a referral, but

also copays and deductibles may apply.

If you pursue your case through arbitration

and your trial results end in your favor, we will rebill your No-Fault carrier and reimburse

you and your private insurance company. If you have any more questions regarding

your No-Fault, please check with the front desk.

I hereby, agree that the above information is not false, or misleading. All information

on this form is complete and accurate to the best of my ability.

Patient Signature: _________________________________ Date: ________________

If you are a guardian or representative of the patient please sign below:

Signature: ________________________________________ Date: ________________

Relationship to Patient: _______________________________________

No Fault Patient Form