Carr PT Patient Registration & Financial Responsibility Form

Patient Registration & Financial Responsibility Form

Carr Physical Therapy & Sport Performance 417-766-6037
PATIENT INFORMATION
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleOther/Prefer not to say
Phone Number*
Ok to text this number
Email Address*
example@example.com
Place of Employment (Company Name)
Physician Name
Physician Phone Number
Please enter a valid phone number.
EMERGENCY CONTACT
Emergency Contact Name*

First NameLast Name
Relationship to Patient*
Contact Phone Number*
Please enter a valid phone number.
HOW WILL YOUR VISIT BE BILLED?
SELECT ONE:*

InsuranceSelf-Pay ($90/visit)Workers CompensationMotor Vehicle Accident/ Attorney/ Lien
Upload Insurance Card (Front of Card)

Cancelof
Upload Insurance Card (back of card)

Cancelof
Insurance
Policy Holder Name*
Policy Holder Relationship*

SelfSpouseChildOther
Secondary Insurance (if applicable)
Secondary Insurance Card (front of Card)

Cancelof
Secondary Insurance Card (back of Card)

Cancelof
WORKERS COMPENSATION
Employer/Worker's Compensation Carrier
Claim number
Adjuster Name
Adjuster Email
example@example.com
Adjuster Phone
Please enter a valid phone number.
MVA / ATTORNEY / LIEN
Attorney Name*
Attorney Phone*
Please enter a valid phone number.
Attorney Email*
example@example.com
Date of Injury*

MonthDayYear
Date
Claim Number*
At-Fault Insurance*
Adjuster Name
Adjuster Email
example@example.com
Adjuster Phone
Please enter a valid phone number.
ASSIGNMENT & FINANCIAL RESPONSIBILITY
I authorize Carr Physical Therapy & Sport Performance to bill my insurance or designated payor as a courtesy. I understand that insurance is a contract between myself and my insurance carrier, and I am financially responsible for all charges not covered by insurance, including deductibles, copays, coinsurance, non-covered services, or denied claims.
PAYMENT POLICY & CREDIT CARD ON FILE
All self-pay, insurance, lien, and performance patients are required to keep a valid credit or debit card on file. Your card will be charged for copays and self-pay visits on the day of service, and for any remaining balance once we receive the Explanation of Benefits (EOB) from your insurance.

Balances must remain in good standing to continue care. Services may be paused until the account is brought current.
INSURANCE BENEFIT RESPONSIBILITY
Carr Physical Therapy & Sport Performance submits claims to your insurance as a courtesy. It is the patient’s responsibility to know and understand their insurance benefits, including coverage, deductibles, copays, coinsurance, authorization requirements, visit limits, and network status. Any questions regarding your coverage, benefits, or claim status must be directed to your insurance carrier. We do not contact your insurance on your behalf regarding eligibility, benefits, claim disputes, visit limits, or authorization issues. Patients are responsible for resolving any insurance-related concerns directly with their insurance carrier.
Cardholder Signature (Required)

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CREDIT CARD AUTHORIZATION
I understand that Carr Physical Therapy & Sport Performance requires a valid credit or debit card to be kept on file. My card information will be collected securely by staff (by phone or in person) and stared in our PCI-compliant payment system. I authorize Carr Physical Therapy & Sport Performance to charge my card for copays, self-pay visits, and any patient responsibility remaining after my insurance has processed my claim.
Patient / Guarantor Name*
Signature*

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Date Signed*

MonthDayYear
Date
Should be Empty:

Patient Registration & Financial Responsibility Form

PATIENT INFORMATION

EMERGENCY CONTACT

HOW WILL YOUR VISIT BE BILLED?

Insurance

WORKERS COMPENSATION

MVA / ATTORNEY / LIEN