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Patient Information Sheet – Please Print

VIEWS: 6 PAGES: 4

									                                      West Texas Therapy Services
                                        4304 Andrews Hwy – Midland, TX 79703
                                           http://www.westtexastherapy.com
                                              Telephone: (432) 570 – 7850

                                        Patient Information Sheet – Please Print

Patient Name: _____________________________________________________________________________
                            (First)                           (MI)                              (Last)

Mailing Address: __________________________________________________________________________
                                                    (City/State)                   (Zip Code)

Home Phone: __________________________________ Cell Phone: _________________________________

SS#: ________________________ Sex: ________ Date of Birth: ____________________ Age: ________

Employer: ____________________________________ Occupation: _________________________________

Marital Status (Circle One): Married        Single Divorced Widow/Widower

If married, Spouse’s Name: _____________________ Birth date: _____________ SS#: __________________

Spouse’s Employer: ____________________________ _ Occupation: _________________________________

If minor, Parent’s or Guardian’s Name: _________________________ Home Phone: ___________________

Parent/Guardian Employer: _____________________________ Occupation: __________________________


Card Holder Information / Person Responsible for Payment:

Relationship to patient (circle one):    Self   Spouse     Parent    Other: _______________________

Name: _______________________________________ Home Phone:________________________________

Address: ________________________________________________________________________________
                                                    (City/State)                   (Zip Code)

SS#: ________________________ Sex: ________ Date of Birth: ____________________ Age: ________

Employer: ____________________________________ Occupation: _________________________________


Insurance Information:

Primary Insurance: _____________________________ Secondary Insurance: _________________________
Address: _____________________________________ Address: ___________________________________

Name of Policy Holder: __________________________ Name of Policy Holder: _______________________

Policy Number: ________________________________ Policy Number: _____________________________

Group Number: ________________________________ Group Number: _____________________________
                                   West Texas Therapy Services
                                     4304 Andrews Hwy – Midland, TX 79703
                                        http://www.westtexastherapy.com
                                           Telephone: (432) 570 – 7850


Medical Information about the Patient:

Patient Name: ____________________________________________________________________________

Referring Physician: _______________________________________________________________________

Have you ever been a patient of ours in the past? (circle one)    YES      NO

If yes, When? _________________________________ Same Injury? (circle one)               YES     NO

How did you hear about our clinic? (circle one) Physician        Friend/Relative   Internet   Insurance Other

Describe your current medical ailment: ________________________________________________________

________________________________________________________________________________________



___ Neck                 ___ Shoulder – R or L          ___ Finger – R or L          ___Leg – R or L

___ Upper Back           ___ Arm – R or L               ___ Wrist – R or L           ___ Ankle – R or L

___ Lower Back           ___ Elbow – R or L             ___ Hip – R or L             ___ Foot – R or L

___ Tailbone             ___ Hand – R or L              ___ Knee – R or L            ___ Toe – R or L



Date ailment first occurred: _______________________

Have x-rays been taken? _________________________

Did this injury happen on the job? _________________ Are you claiming workers’ compensation? ________

Have you notified your employer? _________________

If you are claiming workers’ compensation, please describe how the accident occurred:

________________________________________________________________________________________

________________________________________________________________________________________
                                    West Texas Therapy Services
                                      4304 Andrews Hwy – Midland, TX 79703
                                         http://www.westtexastherapy.com
                                            Telephone: (432) 570 – 7850




                   Patient Authorization for Release of Insurance Benefits

I, ______________________________, hereby authorize RG2, PC, dba West Texas Therapy Services to
apply for benefits from my insurance company and that these benefits be made payable directly to RG2, PC dba
West Texas Therapy Services, (or in case of Medicare Part B benefits, to myself or to the party who accepts
assignments). I certify that the information I have reported, with regard to my insurance, is correct and I further
authorize the release of any necessary information – including medical information for this or any related claim,
to the above billing agent (or in the case of Medicare Part B benefits, to the Social Security Administration and
Centers for Medicare & Medicaid Services and/or my secondary insurance carrier in order to determine benefits
to which I may be entitled). I permit a copy of this authorization to be used in place of the original. This
authorization may be revoked by me or the above carrier at any time in writing.


         _____________________________________                      ____________________________
                   Patient Signature                                            Date




                                    Patient Financial Responsibility
I hereby authorize payment directly to RG2, PC dba West Texas Therapy Services the medical benefits, if
any, otherwise payable to me for services provided. It is understood that any monies received from the
insurance company named above, over and above my indebtedness, will be refunded to me when my bill is paid
in full. By executing this agreement, I am agreeing to pay for all services that are received. I understand my
insurance may or may not cover the cost of Physical Therapy. I want to receive this item or service and I will
pay for it if my insurance does not cover the cost. By signing below, I agree to personally guarantee payment if
my insurance does not cover the cost (in full) of Physical Therapy. I also understand should this matter be
placed in the hands of an attorney for collection, I am financially responsible for additional charges (attorney
fees and court costs). I agree to pay interest on the outstanding balance at the rate of 1.5% per month as well as
reasonable attorney fees (not to exceed 20%) and court costs with regard to the same.


         _____________________________________                      ____________________________
                   Patient Signature                                            Date
                                  West Texas Therapy Services
                                    4304 Andrews Hwy – Midland, TX 79703
                                       http://www.westtexastherapy.com
                                          Telephone: (432) 570 – 7850



                     Consent and Acknowledgement of Receipt of Privacy Notice
                         and Authorization to Release Patient Information


I understand that as part of the provision of healthcare services, West Texas Therapy Services creates and
maintains health records and other information describing among other things, my health history, symptoms,
examination and test results, diagnoses, treatment, and any plans for future care or treatment.

I have been provided the opportunity to read the Notice of Privacy Practices of West Texas Therapy Services.
Additionally, I have been given the opportunity, at my request, to receive a copy of the Notice of Privacy
Practices of West Texas Therapy Services. I understand that the organization reserves the right to change their
Notice and practices.

By signing this form, I consent to the use and disclosure of protected health information about me for the
purposes of treatment, payment and health care operations. I have the right to revoke this consent, in writing,
except where disclosures have already been made in reliance on my prior consent.




Information regarding my medical treatment and billing information at West Texas Therapy Services may be
released to the following person(s):


Name:                                                     Relationship to patient:


___________________________________________               _________________________________________


___________________________________________               _________________________________________


___________________________________________               _________________________________________




___________________________________________               _________________________________________
           Patient printed name                                            Date



 ___________________________________________
Patient signature (or Guardian)

								
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