Name:

Date of Birth:

Address:

Town:

State:

Zip Code:

Home Phone:

Work Phone:

Marital Status:

Age:

Social Security #:

Referring Physician:

Telephone:

Primary Doctor:

Who should be contacted in case of an emergency?

Name

Home Phone:

Work Phone:

** If you have a specialist copay you will also have a copay (per visit) with Physical Therapy

Insurance Information:

Name of Primary Insurance:

Address:

Phone:

Effective Date of Coverage:

Insurance ID#:

Subscriber Name:

Subscriber Date of Birth:

Subscriber SS#:

Name of Secondary Insurance:

Address

Phone:

Effective Date of Coverage:

Insurance ID#:

Subscriber Name:

Subscriber Date of Birth:

Subscriber SS#:

** If you have Workers Comp. or No-Fault you must also fill out Private Insurance Info. as a back up.

Workers Compensation or No-Fault:

Name of Insurance Carrier:

Address:

Adjuster Name:

Telephone #:

Employer:

Telephone #:

Address:

Case Number:

Job Title:

Date of Accident:

I authorize the release of medical information necessary to process claims for "Orthopeadic and Wellness Center", Physical Therapy Department. I also authorize payment of medical benefits to "Thomas S. Eagan, MDPC" for services rendered in the Physical Therapy Department. If I owe any copayments, deductibles, or have been denied by my Insurance Company, I will be responsible for any remaining balances.

Signature:

Date: