Insurance Information Form

Insurance Information Form
Patient's Name (as it appears on the Insurance Card)*
Patient's Date of Birth*
Patient Gender*
Who is the Primary Policy Holder?*
Primary Policy Holder's Name *
Primary Policy Holder's Date of Birth*
Is the policy holder address the same as the patient's address?*

YesNo
Policy Holder Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Payment Policies: Health Insurance

If you would like to use health insurance to cover your physical therapy appointment, we must receive your completed information at least one business day before your appointment. If we do not receive the information in advance, you may pay the self-pay rates at time of service and be reimbursed once insurance benefits are verified.

Patients with an unmet deductible, co-payment, and co-insurances are expected to pay the co-pay at the time of service.

Patients are responsible for payment for for services, tape/equipment, and other fees not covered by the insurance company.

Payments that are not made within 30 business days may be subject to a late fee.
Signature*

Clear
Name of Person Responsible for Payment*
Preferred Email Address for Billing Statements*
example@example.com
Phone Number of Person Responsible for Payment*
Please enter a valid phone number.
Name of Insurance Company*
Policy ID #*
Group ID #*
Upload Your Insurance Cards Below.

If your image is too large, please click the button at the bottom.
Photo of Front of Insurance Card*

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Photo of Back of Insurance Card*

Cancelof
I will submit my photos on the attached link in the next page
Should be Empty: