Intake Form Family Physical Therapy and Wellness, LLC Please enable JavaScript in your browser to complete this form.Patient Information: *FirstLastGender: *MaleFemaleDate of birth: *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SS#:Address: *City: *State: *Zip Code: *Phone #: *Email * Marital Status:SingleMarried Divorced Windowed Domestic PartnerEmployer's Name:Occupation:Physician's Name: Diagnosis:Injury:Allergies or Medical Precautions:Emergency Contact (Name): *Emergency Phone #: *Insurance TypePPOHMOPOSMedicareAutoWORK COMPOtherPrimary Insurance:Insurance Provider Name: *Claims mailing address and phone #:ID/Policy/Claim #: *Group #: *Main Subscriber Name: *Rel. to patient: *SelfChildDomestic PartnerSpouseSubscriber DOB: *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Subscriber Employer:Secondary Insurance:Insurance Provider Name:Claims mailing address and phone #:ID/Policy/Claim #:Group #:Main Subscriber Name:Rel. to patient:Subscriber Name:Subscriber DOB:MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Subscriber Employer: I authorize Family Physical Therapy and Wellness, LLC and its billing agency to bill my insurance company directly for the covered portion of charges, and I authorize payment of benefits directly to Family Physical Therapy and Wellness, LLC. I authorize Family Physical Therapy and Wellness, LLC and its billing agency to release medical or other information necessary to process this claim. I understand that I am responsible for my physical therapy charges, and I agree to pay my deductible, my co-insurance or co-payment, and any charges not reimbursed by my insurance carrier. I understand that some insurance companies require medical or administrative pre-authorization for treatment, or have reimbursement limits on physical therapy treatments. I understand I am responsible for knowing and meeting the requirements for my insurance plan. Patient's signature (type your name): * Date signed: *Submit
