New Patient Form

New Patient Information
Date

MonthDayYear
Date
Please provide us with your Texas Driver's License and Insurance Card(s) Patient Information
Name
Date of Birth

MonthDayYear
Date
Age
Sex

MaleFemale
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone #
Mobile Phone #
Employer Name
Work Phone #
Emergency Contact Person Name
Emergency Contact Person Phone #
Primary Care Physician
Primary Care Physician Phone #
Pharmacy Phone #
Phone# How did you find out about us?
How did you find out about us
Email
example@example.com
Insured's Information: Policy Holder's Name
Relation
Date of Birth

MonthDayYear
Date
Sex

MaleFemale
S.S. #
TDL #
Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Name
Employer Phone #
Insurance Information
Name of Insured
Group #
Primary Insurance Policy #
SS #
Date of Birth

MonthDayYear
Date
Insurance Address
Insurance Phone #
Secondary Insurance Policy #
Group #
Date of Birth

MonthDayYear
Date
Insurance Address
Insurance Phone #
ASSIGNMENT OF INSURANCE BENEFITS

I hereby authorize and request my insurance company to pay directly to Motion Physical Therapy the amount due on my claim, for services to me or my dependent. I further agree that should the amount be insufficient to cover the entire medical and surgical expenses, I understand and agree that (regardless of my insurance status), I am ultimately responsible for the balance of my account for any professional services rendered. I have read all the information on both sides of this form and have completed the above answers. I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in my status or in the above information. A photocopy of this agreement shall be considered as effective and valid as the original.

AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize Motion Physical Therapy to release any medical information acquired in the course of my examination or treatment as may be necessary for the completion of my insurance claims to any insurance carrier, hospital or health plan.

I understand that if I cancel more than 24 hours in advance, I will not be charged. I understand that if I cancel less than 24 hours in advance, I will pay a cancellation fee of $40.00. This fee will be paid at the time of my next appointment. Motion Physical Therapy reserves the right to terminate my treatment if I cancel my appointments with unreasonable frequency and/or without proper notice. (Initial)

I understand that I am a patient of Motion Physical Therapy which is a subsidiary of Center for Spine, Sports & Physical Medicine, P.A. My care is the exclusive responsibility of physical therapy practitioners at Motion Physical Therapy, as well as any other practitioners who also practice at this location. I am not receiving any Home Health Care at this time, nor will I receive Home Health Care while I am receiving outpatient Physical Therapy.

Complaints regarding non-compliance with the Physical Therapy Compliance Act, or regarding any licensee under the act, should be directed to the Texas Board of Physical Therapy Examiners at 1-800-821-3205.
Patient Guardian Signature

Clear
Date

MonthDayYear
Date
Guarantor Signature

Clear
Date

MonthDayYear
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Should be Empty: