Intake - Katy

Spero Rehab - Katy

Patient Intake Forms
Full Name *

First Name Middle Name Last Name
Sex

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Date of Birth *

- Month - Day Year Date Picker Icon
Phone Number *

- Area Code Phone Number
Social Security Number
Please provide here or in person on your first visit.
E-mail *
Ordering Doctor *
Name, Phone Number, Fax Number
INSURANCE INFORMATION
Insurance Company
Primary Subscriber's Name - if different than patient
If not the patient, please include full name and relationship to patient
Primary Subscriber's Date of Birth
Insurance Phone Number
Member ID
Group Number
Claims Mailing Address on Card
**Only fill out your Secondary Insurance information if you have Medicare as a primary. We do not bill secondary insurances unless you have Medicare as a primary.
Seconday Insurance Company
Insurance Phone Number
Member ID
Group Number
Claims Mailing Address on Card
POLICIES AND PROCEDURES

By signing below you are acknowledging you have read and you are acknowledging acceptance of these terms and conditions.
I authorize that the payment of my insurance benefits be made directly to Spero Rehab for all services delivered. If I am paid directly on accident, I will promptly pay Spero Rehab all monies paid to me. I further authorize the release of any medical or other information pertinent to my case to any insurance company, adjuster, or attorney involved in the case for the purposes of processing claims and securing payment of benefits.

I understand that all payments designated as "the patient's responsibility" such as co-insurances and deductibles are due and payable at the time of service or statement receipt. I guarantee I will pay the amount deemed "my responsibility" by my insurer by the statement due date.

I certify that the information I have provided Spero Rehab for payment including, but not limited to related accidents, illnesses or other insurers is accurate and truthful.

We have a strict CANCELLATION POLICY. We must be notified within 24 hours of your appointment if you choose to cancel. We have very limited space on our schedule due to high demand so for the well-being of all of our patients we must enforce this. This fee is $60.

If you are more than 30 minutes late to your treatment session without calling you will be charged a late fee of $30.

Returned check charge of $35 and all future payments must be made with check or credit card.

There is a $25 medical records fee if you would like (or any requesting party would like) a full copy of your medical chart.

We check your therapy benefits as a courtesy to you. It is ultimately your responsilbity to know what is your financial responsibility and what your visit limits are. If these are exceeded for any reason you will be held financially responsible. We do work directly with your insurance company so we will help you keep track.

If I chose to release my medical records (specified below) I understand the following:

This authorization does not expire. If you do choose to change your disclosure choices you can do so in writing.

Spero Rehab is not responsible for the redistribution of medical records after they are released from our care per your instruction.
Check only ONE *

Do not release any information unless required by law or related to treatment or payment ALL records regarding my care at Spero Rehab to any requesting party Limited information ________________________________________________________________
Credit Card On File:

If you would like to leave your Credit Card on file, please fill in the blanks below. You do have the option to add your card when you get the the office. This allows for ease of collecting your deductibles, copays, or co-insurance.
Type of Card:
Name on the Card:
Credit Card Number:
Expiration Date:
Security Code
Billing Address:
NECESSARY DOCUMENTS

To complete your intake process, please use your phone and take a picture of both your drivers license, as well as, the front and back of your insurance card. Then you can either upload them to this website or email them to us at contact@sperorehab.com All of this can be done very easily from your phone and save you time once you arrive at our facility. You can also upload from your computer. This is not required - but we do recommend it. Thank you!
Driver's License
Front of Insurance Card
Back of Insurance Card
Doctor's Order
Spero Rehab Pre Exam Questionnaire
Briefly describe what you will be coming for and how it is effecting your daily life *
List all current medications: *
List all relevant surgeries and approximate date: *
List all other relevant medical symptoms or conditions we should be aware of: *
Patient Signature *
By typing your name above, you acknowledge that all information provided is up to date and correct.
Today's Date *
Should be Empty:

Spero Rehab - Katy

INSURANCE INFORMATION

POLICIES AND PROCEDURES

Credit Card On File:

Spero Rehab Pre Exam Questionnaire