Insurance Information Form

Patient Name*

First Last

Have you had Physical Therapy This Year?*

Yes
No

Primary Insurance Provider*

Primary Identification/Subscriber Number*

Primary Group/Claim #*

Primary Insurance Phone Number*

Primary Insurance Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Policy Holder Date of Birth*

MM

DD

YYYY

Policy Holder Name*

First Last

Policy Holder SSN*

Relationship To Patient*

Secondary Insurance Provider*

Secondary Insurance Identification/Subscriber Number*

Secondary Insurance Group Claim Number*

Secondary Insurance Phone Number*

Secondary Insurance Policy Effective Date*

Policy Holder Name*

First Last

Policy Holder Date of Birth*

MM

DD

YYYY

Secondary Insurance Policy Holder SSN*

Relationship To Patient*

Release of Information: Orofino Physical Therapy may disclose all or any part of my records to any party or organization responsible for all or part of my therapy charges. Orofino Physical Therapy may disclose all or part of my record to other health care providers including but not limited to, hospitals and physicians. I further agree that Orofino Physical Therapy, may release all or any part of my record to any federal, state or local government body when, in the opinion of Orofino Physical Therapy, such bodies may be liable for all or part of my charges in relation to my care and treatment pursuant to statute or rule.*

I Agree

Financial Consent: I agree to be responsible for payment of all outpatient physical therapy charges which are not covered by insurance, and when appropriate, to submit applications to federal, state and county programs. I understand Orofino Physical Therapy, will bill me, my family, and/or other responsible parties for services provided.*

I Agree

Assignment of Insurance Billing: I and/or the responsible party voluntarily assign Orofino Physical Therapy, PLLC and it's independent contracting providers the right to pursue their respective claims for reimbursement from any insurance policy or policies providing coverage for services provided.*

I Agree

No-Show/Cancellation Policy: All patients who do not cancel their appointment within 24-hours or more of their scheduled appointment will be charged $20 at their next appointment. This fee can be waived for patients who reschedule their appointment within that week. Patients who do not show up to their appointment and do not call to cancel will recieve a $25 "No-Show" fee.*

I Agree

Name of Responsible Party*

First Last

Date*