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    188宝金博页面版: KCP Phyical therapy

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    内容提示： PATIENT INFORMATION Patient Name __________________________________ DOB ________________ Patient’s Address ____________________________________________________ City _____________________________ State ______ Zip Code _______________ Home Phone # ____________________ Work Phone # _____________________ Email _____________________________________________________________ Patient’s Status: Married / Single / Other Employed / Student / Other Emergency Contact _____________________ Relationship _________...

    文档格式：DOC | 页数：5 | 浏览次数：22 | 上传日期：2016-03-22 13:01:21 | 文档星级：
    PATIENT INFORMATION Patient Name __________________________________ DOB ________________ Patient’s Address ____________________________________________________ City _____________________________ State ______ Zip Code _______________ Home Phone # ____________________ Work Phone # _____________________ Email _____________________________________________________________ Patient’s Status: Married / Single / Other Employed / Student / Other Emergency Contact _____________________ Relationship ________________ Emergency Contact Phone # __________________________________________ **** PLEASE HAVE YOUR INSURANCE CARD AVAILABLE **** Financial Policy I understand that KCP has verified my benefits as a courtesy to me. This authorization is not a guarantee of payment. Any deductible, Co-pay or Co-insurance will be collected at the time of service. At the end of my treatment my chart will be reviewed. Any inaccurate information provided by my insurance company regarding deductible, copay or coinsurance that results in an outstanding balance due would be my responsibility. Refunds will be issued as appropriate. Client Signature: _____________________________ Date: ________________ Do you have “Automatic Crossover” on your Medicare policy? _____ YES _____ NO (Automatic Crossover means that Medicare forwards your claim to your secondary insurance policy) PATIENT TREATMENT INFORMATION How did you hear about us? What are we seeing you for? ___ Neck ___ Back ___Upper Extremity ___ Lower Extremity General Symptoms __________________________________________________

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