Heading hidden

OCCUPATIONAL THERAPY FOR PRODUCTIVE LIVING

Personal Information:

Patient Name: _________________________

DOB: _________ SSN:__________________

Insured Name: _________________________

Home Phone: __________________________

Business Phone: ________________________

Cell Phone: ____________________________

Email: ________________________________

Address: ______________________________________________________________________________________________________________

Emergency contact (REQUIRED):
Name and Number(s):_____________________________________________________________________________________________________

History of Physical Therapy/Occupational Therapy:

Have you received physical or occupational therapy in the last year?  Yes No

Where and When? ________________________________________________________________________________________________________

________________________________________________
Prescription for Physical Therapy/Occupational Therapy:
Do you have a prescription for PT or OT?    Yes   No
How did you hear about our facility?

Doctor: ___________________________

Friend: ___________________________

Advertisement: _________________________

Other: ___________________________

CURRENT PHYSICIANS:

PCP: __________________________Phone:_________________

Cardiologist: ___________________________

Orthopedist: ___________________________

Rheumatologist: ________________________

Neurologist: ____________________________________________

Billing:

Primary Insurance: ___________________________

Member #:__________________________________

Secondary Insurance: _________________________

Member #:__________________________________

OCCUPATIONAL THERAPY FOR PRODUCTIVE LIVING
I understand that I am financially responsible for all charges whether or not paid by insurance. I am aware that I be subject to a $30.00 fee for all missed appointments and for cancellations not received at least 24 hours in advance.
Dated this _________ day of ___________, 20___.

_____________________________________
Signature of Policyholder/Patient/Guardian (if under 19 years of age)

______________________________________
Signature of Claimant, if other than Policyholder

Print Friendly, PDF & Email