New Patient Enrollment Form

New Patient Enrollment
Personal Information
Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
Date
Sex*
E-mail*
example@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number:*
Marital Status
Employer
How Did You Hear About Us?
Upload Driver's License Pictures

Front and Back
Cancelof
Take photo of driver's license:
Insured Party/Responsible Party

(Leave Blank if Same as Patient)
Social Security Number
Date of Birth

MonthDayYear
Date
Relationship
Name

First NameMiddle NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number:
Marital Status
Upload Insurance Card Pictures in Advance to Visit

Front and Back
Cancelof
Take photo of Insurance:
Emergency Contact Information
Emergency Contact:*

First NameLast Name
Relationship*
Contact Number*

Patient Authorization Record
Authorization for Treatment
I hereby give authorization for the performance of such rehabilitation procedures as permitted by Associates Physical Therapy Statutes under the appropriate scope of practice are, in the judgment of my Therapist, deemed necessary.*
Initial Here
Authorization for Release of Information
I agree that Associates Physical Therapy may provide information from my medical record to persons involved in my medical case. I authorize the release of medical information necessary to obtain payment of any benefits available to me to Associates Physical Therapy for services rendered. I agree that Associates PhysicalTherapy may obtain information from others who have provided medical care to me and/or are responsible for the payment of all or part of my bills when this information is needed in order to treat, bill, and/or receive payment. The above party may disclose health information to the following recipients:*
Initial Here
Recipient

First NameLast Name
Recipient Phone Number
Please enter a valid phone number.
Recipient

First NameLast Name
Recipient Phone Number
Please enter a valid phone number.
Authorization for Release of Payment
I authorize that direct payment of any benefits available to me be released to Associates Physical Therapy for services rendered.*
Initial Here
Patient Agreement
I agree to pay Associates Physical Therapy charges for services rendered to me during my course of treatment. I agree to pay those charges which may not be paid by my health insurance and are my responsibility per my insurance benefit. If I do not pay for charges that are my responsibility, I agree to pay Associates PhysicalTherapy collections costs including attorney and court fees.*
Initial Here
Photo Consent
I consent to Associates Physical Therapy using my photo and or a video of me on their website and social media page. At any time, I may revoke this consent.
Initial Here
Patient Certification, Consent to Treat, HIPPA and Signature
I have read “Notice of Privacy Practices” mandated by HIPPA.
I certify that all of the information provided herein is true and correct, I provide Consent to Treat for Therapy and Notice of Patient Information Practices.
Patient/Guardian Signature*

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Date

MonthDayYear
Date
Should be Empty:

New Patient Enrollment

Personal Information

Insured Party/Responsible Party

Emergency Contact Information

Patient Authorization Record

Authorization for Treatment

Authorization for Release of Information

Authorization for Release of Payment

Patient Agreement

Photo Consent

Patient Certification, Consent to Treat, HIPPA and Signature

I have read “Notice of Privacy Practices” mandated by HIPPA.