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PRIORITY PHYSICAL THERAPY & REHAB

21700 Northwestern Hwy, Suite 835, Southfield, MI 48075
Phone: (248) 996-8791 Fax: (248) 996-8806
www.priorityrehab.org

Insurance Information:

(Please present cards; please list coverage in the order it is to be filled)

Primary insurance:

Subscriber:

Subscriber ID #:

Group #:

Phone:

Date of Birth: ×

SSN:

Subscriber’s Employer:

Relation to Subscriber:

SELF

SPOUSE

CHILD/DEPENDENT

Secondary insurance:

Subscriber:

Subscriber ID #:

Group #:

Phone:

Date of Birth: ×

SSN:

Subscriber’s Employer:

Relation to Subscriber:

SELF

SPOUSE

CHILD/DEPENDENT

WORKER'S COMPENSATION:

INSURANCE CARRIER

Phone

Address:

City:

State:

Zip:

Contact person/Adjuster:

Phone:

Employer:

Phone:

EMPLOYER ADDRESS:

City:

State:

Zip:

LIABILITY: (ATTORNEY, AUTO INSURANCE & THIRD PARTY)

Insurance:

Claim #

Adjuster/Attorney:

Phone

Date of accident: ×

Place of Accident:

Other:

I hereby accept responsibility for the cost of this examination or treatment in the event that the Insurance Company denies this claim.

Patient’s signature:

Date Signed: ×

PRIORITY PHYSICAL THERAPY & REHAB

21700 Northwestern Hwy, Suite 835, Southfield, MI 48075
Phone: (248) 996-8791 Fax: (248) 996-8806
www.priorityrehab.org

Billing Policy, Release, and Authorization

I authorize Priority Physical Therapy & Rehab to bill my insurance company directly for the covered portion of charges, and I authorize payment of benefits directly to Priority Physical Therapy & Rehab. I authorize Priority Physical Therapy & Rehab to release medical or other information necessary to process this claim. I understand that I am ultimately 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 of my insurance plan.

Signature:

Date Signed: ×

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PRIORITY PHYSICAL THERAPY & REHAB

Patient Intake Form

Patient Information:

Marital Status:

Social History:

Are you presently working?

Physical/Emotional demands of present occupation? (High, moderate, minimal)

Family medical History:

Please list 3 goals of Physical Therapy and time frames:

Thank You for Your Patience and Valuable Time!!!

PRIORITY PHYSICAL THERAPY & REHAB

Insurance Information:

WORKER'S COMPENSATION:

LIABILITY: (ATTORNEY, AUTO INSURANCE & THIRD PARTY)

I hereby accept responsibility for the cost of this examination or treatment in the event that the Insurance Company denies this claim.

Patient’s signature:

PRIORITY PHYSICAL THERAPY & REHAB

Medical History

Have you had similar episodes of this current problem in the past? If yes, were you treated with; (circle disciplines, which apply) Physical Therapy, Acupuncture, M.D. Massage Therapist, Chiropractor, Pilates, General Exercise, exercise with trainer, Self-medicated (Advil), ignored it, other,

Have you undergone any special tests for this condition? (X-rays, MRI’s, etc.) If yes, do you know the results?

Please answer the following questions: Yes No

The above is correct to the best of my knowledge.

Patient’s signature:

PRIORITY PHYSICAL THERAPY & REHAB

Billing Policy, Release, and Authorization

Signature:

Your form has been submitted

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