Magnolia Physical Therapy Registration

MAGNOLIA PHYSICAL THERAPY REGISTRATION

Please answer all questions to the best of your ability:

Patient’s Name______

DOB______Address______

City______State____ Zip______

BEST NUMBER TO CONTACT YOU ______SECONDARY CONTACT

NUMBER______

Which method would you prefer to be contacted for appointment reminders (circle one) CALL TEXT EMAIL

Sex: M F Marital Status: S M W D SS#______

Email ______Would you like to receive newsletter and special offers via e-mail? Yes No

Currently Working? Yes No Employer ______

Occupation______Phone: ______

Emergency Contact______Relationship ______Phone:______

Referring Physician______Phone: ______

For office use only: Insurance purchased through the Healthcare Marketplace? Yes_____ No _____ If yes, in which state was the plan purchased?_____ Condition Referred for: ______M.A.P. Discussed with patient ______DATE______INITIALS Referral Source______

Primary Insurance/ Responsible Party Secondary Insurance/ Other

Name of Ins. Name of Ins. Co.:______Co.:______Address: Address: ______Elec. Payor ID (if applicable):______Elec. Payor ID (if applicable):______Phone: ______Fax: Phone: ______Fax: ______Policy Holder’s Name: Policy Holder’s Name: ______Policy # ______Policy # I acknowledge that the above information is true and correct. I hereby authorize treatment and understand the possible benefits and risks of my treatment. I know and agree that Magnolia Physical Therapy, LLC is not responsible for loss or damage to personal items. I irrevocably assign all benefits directly to Magnolia Physical Therapy, LLC. I authorize the release of any medical records necessary to process medical claims. I understand fully that I am responsible for all amounts, including equipment and supplies not covered by my insurance. I understand that I must notify Magnolia Physical Therapy, LLC of any changes in insurance/payer information immediately to avoid delays in the processing of claims. I understand that if my insurance fails to pay for my services, I will be responsible for payment in full within 30 days of notification. I agree to pay all copayments and/or my financial responsibilities at the time services are rendered.

______Patient’s Signature (parent if minor) Date

______Clinic Representative Date