Insurance Information Form - Idaho Physical Therapy - Nampa

Patient Name *

First

Last

Email *

Please enter your email, so we can follow up with you.

Have you had Physical Therapy This Year? *

Primary Insurance Provider *

Primary Identification/Subscriber Number *

Primary Group/Claim # *

Primary Insurance Phone Number *

Primary Insurance Address *

Street Address, City, State, Zip/Postal Code, Country

Policy Holder Date Of Birth

MM/DD/YYY

Policy Holder SSN *

Relationship To Patient *

Secondary Insurance Provider

Secondary Insurance Identification/Subscriber Number

Secondary Insurance Group Claim Number

Secondary Insurance Phone Number

Secondary Insurance Policy Effective Date

Secondary Insurance Policy Holder Name

First

Last

Secondary Insurance Policy Holder Date Of Birth

Secondary Insurance Policy Holder SSN

Secondary Insurance Relationship To Patient

Release of Information: Idaho Physical Therapy may disclose all or any part of my records to any party or organization responsible for all or part of my therapy charges. Idaho Physical Therapy may disclose all or part of my record to other health care providers including but not limited to, hospitals and physicians. I further agree that Idaho Physical Therapy, may release all or any part of my record to any federal, state or local government body when, in the opinion of Idaho Physical Therapy, such bodies may be liable for all or part of my charges in relation to my care and treatment pursuant to statute or rule.* *

I Agree

Financial Consent: I agree to be responsible for payment of all outpatient physical therapy charges which are not covered by insurance, and when appropriate, to submit applications to federal, state and county programs. I understand Idaho Physical Therapy, will bill me, my family, and/or other responsible parties for services provided. *

I Agree

Assignment of Insurance Billing: I and/or the responsible party voluntarily assign Idaho Physical Therapy and it's independent contracting providers the right to pursue their respective claims for reimbursement from any insurance policy or policies providing coverage for services provided. *

I Agree

No-Show/Cancellation Policy: All patients who do not cancel their appointment within 24-hours or more of their scheduled appointment will be charged $20 at their next appointment. This fee can be waived for patients who reschedule their appointment within that week. Patients who do not show up to their appointment and do not call to cancel will receive a $25 "No-Show" fee. *

I Agree

Name Of Responsible Party *

First

Last

Date

MM/DD/YYYY

Additional Information Or Message?