Full Name

Gender

Date of birth

Marital Status

Address

Street Address

Country

State

City

Postal Code

Email *

Phone *

Would you like to receive appointment reminders by email?

Would you like to receive appointment reminders by text?

Emergency Contact

Relationship

Employer

Occupation

Have you had Physical or Occupational Therapy this year for any condition?

PHYSICIAN INFORMATION

Referring Physician

Referring Physician City

NPI

CONSENT FOR TREATMENT

CONSENT FOR TREATMENT *

I the undersigned do hereby agree and give my consent to Beyond Care Physical Therapy & Wellness PC to furnish Physical Therapy care and treatment considered necessary and proper in evaluating and/or treating my physical condition. It is your responsibility to notify our office of any patient information changes (i.e., address, phone number, name, insurance information, etc.)

Signature

Clear

Date

Relationship to Patient

FINANCIAL POLICY AND INSURANCE INFORMATION *

I understand and agree that insurance claim forms will be submitted to my insurance company as a matter of convenience only, and that I am responsible for all chargers regardless of my existing medical coverage. If I do not provide insurance information or inaccurate information, Beyond Care Physical Therapy & Wellness PC will bill me directly for incurred charges, as well as for charges not covered by my insurance plan. If I receive a notice from my insurance company that payment is delayed or denied because additional information required, I will contact my insurance company so that claims may be repossessed and paid. I also authorize Beyond Care Physical Therapy & Wellness PC to furnish information to insurance carriers concerning this treatment. I hereby give authorization for payments of insurance benefits made directly to Beyond Care Physical Therapy & Wellness PC for services rendered. In this event my insurance company forwards payments directly to me instead of Beyond Care Physical Therapy & Wellness PC. I will immediately deliver said payments to Beyond Care Physical Therapy & Wellness PC. I understand agree that I am wholly responsible and liable for payment of all charges assessed for professional services rendered and will pay any sum due upon demand. I understand and agree that if it becomes necessary to commence legal actions for the collection of outstanding charges on my account, I will be responsible for any costs and/or court fees, in addition to the outstanding balance. If I receive payment from the settlement, I will release funds to Beyond Care Physical Therapy & Wellness PC immediately.

Signature of Person responsible for charges

Clear

Date

Relationship to Patient

PRIMARY INSURANCE

Name of Subscriber:

DOB

Relationship to Patient

Other

Insurance Co

Group #/ Name

Member #/ Name

SSN #

SECONDARY INSURANCE

Name of Subscriber (2)

DOB (2)

Relationship to Patient (2)

Other (2)

Insurance Co1 (2)

Group #/ Name (2)

Member #/ Name (2)

SSN # (2)

Please understand that this is not a promise to be paid by your insurance carrier. Claims will be reviewed by your carrier for eligibility and benefits and may be subject to limitations and exclusions.

We have contacted your insurance carrier to verify your eligibility and benefits

for outpatient physical therapy, occupations or speech therapy. We highly recommend that you also verify your benefits with your insurance. You are responsible for any services/charges not covered by your insurance plan, regardless of what was quoted to us by your insurance.