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 in order to verify your benefits and coverage. Once the verification is complete, a copy of your benefits will be emailed to you. You must review and sign the verification in order for us to process the claims through insurance. If we do not receive the signed form, self-pay rates will apply.

If we do not receive the information at least 24 hours prior to your appointment, you may pay the self-pay rates at time of service and be reimbursed once insurance benefit verification is completed.

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.

I have read the above and my payment choice for fees not covered by insurance is indicated below.

I will have a card on file and authorize Carolina Dancer Wellness to charge my card at the time of service. (A card-on-file authorization agreement will be emailed to you and must be completed before the end of the first visit.)I will pay in full (or the estimated charges) in person at each visit.I prefer to receive monthly statements. I understand that this option has a $5 service fee, payment is due within 30 days of receipt, and that a late fee of 10% is applied for payments received after 30 days.

Signature*

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*

Photo of Back of Insurance Card*

I will submit my photos on the attached link in the next page