Progressive Physical Therapy and Rehab., Inc.
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Personal Information |
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Sex: M F |
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Referring Doctor Information |
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UP#:
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Whom may we thank for this referral:
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Family Physician:
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Sex: M F
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Insured Employer Information |
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Emergency Contact Information |
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Other Information |
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Date of Injury (Onset):
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Accident: No Accident Auto Accident Other
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Is this injury an Employment Injury? Yes No
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Employment Status:
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Marital Status: Married Single ٱ Other |
Student: F/T P/T Other |
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Primary Insurance
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Type of Insurance: PPO EPO HMO Managed Care Work Comp M/C Other |
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Patient Relationship To
Insured: Self Spouse Child Other |
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Secondary Insurance Information |
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Type of
Insurance: PPO EPO HMO
Managed Care Work Comp M/C Other |
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Patient Relationship To Insured:
Self Spouse Child Other |
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Insurance Authorization Information |
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Diagnosis: |
ICD-9: |
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Patient Co-Pay %: |
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PTPN |
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Deductible Start Amount $: |
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LIMITS |
Visits/ Yr: |
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Amount/Yr
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PT Authorization #:
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# of Visits
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Patient Authorization, Release and SignatureI authorize treatment by the staff at Progressive Physical Therapy and Rehab. Inc. and authorize the release of information to other health professionals and my insurance company. I authorize payment to be made directly to Progressive Physical Therapy and Rehab. Inc. I have read the above estimation of benefits from my insurance company and agree to verify this information by reading my insurance benefits book or contacting my insurance company. I do not hold Progressive Physical Therapy and Rehab, Inc. responsible for any incorrect or omitted information or for any changes in my future coverage. I also agree that I am responsible for the contract between myself and my insurance company. Patient
Signature:_____________________________________________ Date:___________
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