Patient Registration Form

Client Information/Registration Form
6 Edwin Street, Morgantown, WV 26501

P: 304-292-0173 Fax: 304-292-0174

PlayWorkscdc.com
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Middle Initial
Client Social Security Number
Address

Street Address

Street Address Line 2

City, State ZipState / Province

Postal / Zip Code
Client Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex
Home Phone
Format: (000) 000-0000.
Cell
Work Phone
Email Address
example@example.com
Which phone number is best to reach you
Format: (000) 000-0000.
RESPONSIBLE PARTY
Mother's Name
Mother's DOB
Mother's SSN#
Father's Name
Father's DOB
Father's SSN#
Street Address (if different from above)
City, State, Zip
Additional Caregiver Name (if applicable)
Caregiver Telephone
Format: (000) 000-0000.
INSURANCE
Referring Physician
Diagnosis
Has the Client received any therapies within the past 6 months?
Primary Insurance Provider
PLEASE ATTACH A COPY OF ALL INSURANCE CARDS FRONT AND BACK

Cancelof
PLACE OF EMPLOYMENT
Prescription from Referring Physician

Cancelof
Is Client enrolled in any WAIVER Programs?
Name of Agency
Service Coordinator Name
Coordinator Contact Number
EMERGENCY CONTACT NAME
RELATIONSHIP TO CLIENT
EMERGENCY CONTACT PHONE #:
Format: (000) 000-0000.
CONSENT FOR OCCUPATIONAL, PHYSICAL, AND/OR SPEECH THERAPY
I am entering PlayWorks Child and Adult Therapies voluntarily for the purpose of occupational, physical and/or speech therapy and do hereby consent to such treatment. I am responsible for paying for services provided to me, which may include collection fees. I authorize PlayWorks Child and Adult Therapies to release my medical records to any person or company who many need them for my continuing care, for payer review of medical services provided (utilization review) and/or for payment of my account.
Signature of insured/guardian (use your finger/mouse to sign the box)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ASSIGNMENT AND RELEASE, GUARANTEE OF ACCOUNT
I hereby authorize and assign payment directly to PlayWorks Child and Adult Therapies for any medical benefits otherwise payable to me. I hereby authorize PlayWorks Child and Adult Therapies to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. I understand that I am financially responsible for all charges whether or not paid by insurance. I accept responsibility for payment of the deductible, co-payment and non-covered services.
Type a question
Signature of insured/guardian (use your finger/mouse to sign the box)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
**MY SIGNATURE INDICATES THAT I HAVE READ AND UNDERSTAND THE POLICIES OF PLAYWORKS CHILD AND ADULT THERAPIES AS DESCRIBED WITHIN THIS DOCUMENT.
Should be Empty:

Client Information/Registration Form

RESPONSIBLE PARTY

INSURANCE

CONSENT FOR OCCUPATIONAL, PHYSICAL, AND/OR SPEECH THERAPY

ASSIGNMENT AND RELEASE, GUARANTEE OF ACCOUNT