[FrontPage Save Results Component]

Aquatic Physical Therapy & Beyond, LLC
Patient Information

 
Title: First Name:   MI:   Last  Name:   Nick Name:  
                           

  Address:    City:       St:                        Zip:
 
 Phone Home:     Cell:   Work:     Email: 
                   
  Date of Birth
   Soc. Sec.#    Sex
 

Marital Status:  Married   Widowed   Single   Divorced   Separated
    Employment:     Retired    Full  Time   Part Time  N-None

If you are not the primary insured on any of your insurance policies or you are the Parent and or Guardian of the patient, please complete the following section.  Otherwise, continue to the Emergency Contact Information Section.
Primary Insured       Title:   First Name:    MI:       Last Name:                         
                                                                                                 
   DOB:    SS#:    Home Phone:     Work:    Cell: 

Emergency Contact Information
  Name of a person to contact in case of an emergency.     Phone Number                  Relationship to patient        Preferred Hospital if any
                         

Insurance Information
  Primary Insurance Co. Name
 
  Member ID#
 
  Cust. Service Ph. # (Back of Card)
  		  Insurance #2 Name
 
  Member ID#
  
  Cust. Service Ph. # (Back of Card)
 		   Insurance #2 Name
 
  Member ID#
 
  Cust. Service Ph. # (Back of Card)
  

Medical Information / Issues
  Do you have a prescription?      Referring Doctor's Name
     		     Doctor's Phone:  
          Doctor's Fax:  
   Description of the medical issues you are dealing with:  
 
   If you are dealing with an accident related injury, please complete the following:
   Employment Related:  Yes  No            Accident Related:  Auto   Other  No                    
   Date of first symptom or accident:      State the injury took place in:
                                                                                       
  Description of the accident / injury :  
 
By signing below or submitting this form, I authorize the release of any medical or other information necessary to obtain payment from my insurance company or any other third party that is liable for payment for services rendered.   I hereby authorize and direct my insurance company or companies, attorney or any other entity financially covering my treatment at Aquatic Physical Therapy & Beyond, LLC to make direct payment to Aquatic Physical Therapy & Beyond, LLC under any and all applicable coverage, including major medical, for covered charges for services rendered.  I authorize Aquatic Physical Therapy & Beyond, LLC to complain to my insurance(s) company and/or the insurance commission on my behalf.  I also authorize the use of my medical information for managing my health care as well as any related services. In addition, I authorize the use of my medical information for the practice’s health care operations for the purposes of management or administration of the practice and of offering quality health care services.  By signing below I am confirming that I have been given a detailed summary of the NOTICE REGARDING PRIVACY OF PERSONAL HEALTH INFORMATION.
                   
Patient Initials:       Date:     Patient Signature after printing:______________________________