PATIENT INFORMATION
 
Patient Name: _________________________________
Address: ______________________________________
City: ___________________ State: _____ Zip Code: ________
Home Telephone #: ____________________ E-Mail Address:__________________
Date of Birth: _______________________
Social Security Number: _______-______-__________

MARITAL STATUS: M S D W (Circle one)
Spouse’s Name: ________________Patient’s Employer: _____________________
Address:______________________________
City: ___________________ State: ___Zip Code: ______
Work Telephone #: ____________________ 
Name of (Primary) Physician: _______________________
Telephone #: ____________________
In case of emergency, who do we contact? ________________________
Telephone # : _________________ Cell Phone #: ___________________
Relationship: _________________
Whom may we thank for referring you to us? __________________

I, ______________________(please print clearly—if minor, parent or guardian
signature) consent to evaluation and treatment by Anchor Physical Therapy, LLC.,
of my problem as diagnosed by my physician.

Please complete the following only if subscriber is not the patient or a minor:

Subscriber Name:________________________Date of Birth: __________________
Employer: _______________________________
Employer Telephone: __________________
Employer Address: ________________________
City: ______________ State: ___ Zip Code: ________

What are you here to be treated for:_______________________________________________
Are services related to a work or auto injury:
(circle one if applicable) WORK AUTO Date of Injury: ____________
Claim Number: __________________
Insurance Carrier: ______________________Telephone: ________________
Address:________________________
Claim Representative: ____________________City: _________________
State: ___Zip: ______ Representative Phone: ____________________

 

 

 

 

ASSIGNMENT OF BENEFITS:
I hereby assign all medical benefits, to include major medical health benefits to which I am entitled, including Medicare, private insurance and any other health plan to Anchor Physical Therapy, LLC. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure payment. If I receive direct payment from my insurance company for my physical therapy treatment, I will be responsible to bring this payment to Anchor Physical Therapy LLC, to be applied to my account for services rendered. I certify this information is true and correct to the best of my knowledge.

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS: Anchor Physical Therapy, LLC. is authorized to provide and request from my referring physician, other physicians and/or my attorney, information regarding my diagnosis and medical condition for physical therapy while under their treatment. Information to be disclosed may include nature of the physical impairment, history, contributing factors, subjective symptoms, diagnosis, prognosis and other information pertinent to my treatment. Photostatic copy of this authorization shall serve in its stead.
Date: ____________________________ Signature: _____________________________________________