R RRRRe eeeeg ggggi iiiis sssst ttttr rrrra aaaat tttti iiiio oooon nnnnF FFFFo oooor rrrrm mmmm J JJJJo ooooy yyyyP PPPPe eeeet tttte eeeer rrrrm mmmma aaaan nnnnn nnnn, ,,,,L LLLLL LLLLC CCCC DX Code ________________________ Date _________________________ Therapist ________________________ P PPPPa aaaat tttti iiiie eeeen nnnnt ttttI IIIIn nnnnf ffffo oooor rrrrm mmmma aaaat tttti iiiio oooon nnnn P PPPPa aaaat tttti iiiie eeeen nnnnt ttttN NNNNa aaaam mmmme eeee(Print)__________________________________________________________________________________ D DDDDa aaaat tttte eeeeo oooof ffffB BBBBi iiiir rrrrt tttth hhhh________________________________ Last Name First Name Initial Street Address________________________________________________________________________________________Cell/Home Phone ____________________________ City_____________________________________________________________State_________ZIP____________________Work Phone ________________________________ Soc. Sec. #_____________________________________Emergency Contact_____________________________________Emergency Phone ____________________________ Sex: G Female G Male Age__________ Marital Status: G Single G Married G Widowed G Divorced G Separated G Other Employer _________________________________________________________Occupation____________________________________________________________________ Referred by________________________________________________________May we acknowledge this referral?_________________________________________________ P PPPPr rrrri iiiim mmmma aaaar rrrry yyyyI IIIIn nnnns ssssu uuuur rrrra aaaan nnnnc cccce eeee P PPPPr rrrri iiiim mmmma aaaar rrrry yyyyI IIIIn nnnns ssssu uuuur rrrra aaaan nnnnc cccce eeeeC CCCCo oooom mmmmp ppppa aaaan nnnny yyyy____________________________________________________________________________ Phone ____________________________________ Ins Claims Address___________________________________________________________City____________________________State_________Zip_____________________ Policy / Member ID ___________________________________________________________________ Group/Account #___________________________________________ P PPPPo ooool lllli iiiic ccccy yyyyH HHHHo ooool lllld dddde eeeer rrrrI IIIIn nnnnf ffffo oooor rrrrm mmmma aaaat tttti iiiio oooon nnnn: (if the patient is not the employee/policy holder) Name____________________________________________________________________________________________________ D DDDDa aaaat tttte eeeeo oooof ffffB BBBBi iiiir rrrrt tttth hhhh__________________________ Last name First Name Initial Address_____________________________________________________City____________________________State______Zip_______________Relationship______________ Soc. Sec#___________________________________________________Employer____________________________________________________________________________ S SSSSe eeeec cccco oooon nnnnd dddda aaaar rrrry yyyyI IIIIn nnnns ssssu uuuur rrrra aaaan nnnnc cccce eeee S SSSSe eeeec cccco oooon nnnnd dddda aaaar rrrry yyyyI IIIIn nnnns ssssu uuuur rrrra aaaan nnnnc cccce eeeeC CCCCo oooom mmmmp ppppa aaaan nnnny yyyy__________________________________________________________________________ Phone ____________________________________ Ins Claims Address___________________________________________________________City____________________________State_________Zip_____________________ Policy / Member ID ____________________________________________________________________ Group/Account #__________________________________________ P PPPPo ooool lllli iiiic ccccy yyyyH HHHHo ooool lllld dddde eeeer rrrrI IIIIn nnnnf ffffo oooor rrrrm mmmma aaaat tttti iiiio oooon nnnn: (if the patient is not the employee/policy holder) Name____________________________________________________________________________________________________ D DDDDa aaaat tttte eeeeo oooof ffffB BBBBi iiiir rrrrt tttth hhhh__________________________ Last name First Name Initial Address_____________________________________________________City____________________________State______Zip_______________Relationship______________ Soc. Sec#___________________________________________________Employer___________________________________________________________________________ R RRRRe eeees ssssp ppppo oooon nnnns ssssi iiiib bbbbl lllle eeeeP PPPPa aaaar rrrrt tttty yyyy (Where should the patient’s portion of the bill be sent, if not to the patient?) Name _________________________________________________________________________________________Relationship ______________________________________ Address________________________________________________________________________________________Phone ___________________________________________ A AAAAs sssss ssssi iiiig ggggn nnnnm mmmme eeeen nnnnt tttta aaaan nnnnd ddddR RRRRe eeeel lllle eeeea aaaas sssse eeee I the undersigned, certify that I (or my dependent) have insurance coverage as noted above and assign directly to the healthcare provider listed at the top of this form all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the healthcare provider to release all information necessary to secure the payment of benefits and to mail patient statements. I authorize the use of this signature on all insurance submissions. Responsible Party Signature Relationship Date