Pediatric New Client Form Page 7
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7INSURANCE INFORMATION
(From insurance card. * all fields required.)
*Primary Insurance Company: __________________________________________________________
PPO
POS
HMO Other ______________________________
*Insurance Type:
*Claims Address: ___________________________________________
*Claims Phone: ___________________________
Clearinghouse ID Number (to be completed by provider): _____________________________________
*Policy Holder/Guarantor: ______________________________________________________________
Parent
Grandparent
Other _________________________
Relationship to Client:
*Policy Number/Member ID: ____________________________________________________________
*Group Plan Number: ________________________
*Policy Name: ___________________________
*Effective Date of Plan: _______________________
*Co-Pay or Co-Insurance: __________________
*Annual Deductible: _________________________ Amount of Deductible Already Paid: ____________
*Restrictions/Limits of Plan: _____________________________________________________________
*Out-of-Network coverage for Physical Therapy _____________________________________________
Policy Holder Information:
Name: ______________________________________________________________________________
Address: ____________________________________________________________________________
City __________________________ State ________ Zip Code: __________________________
Email Address: _________________________ Home Phone: _______________________________
Cell phone: ____________________________
Work phone: ________________________________
Social Security No. of Policy Holder: ________________________________________
Date of Birth of Policy Holder: _______________________ Gender of Policy Holder: M F
If you have any Secondary Insurance, please provide that information here: ___________________________
________________________________________________________________________________________
________________________________________________________________________________________
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