<p> MAGNOLIA PHYSICAL THERAPY REGISTRATION</p><p>Please answer all questions to the best of your ability: </p><p>Patient’s Name______</p><p>DOB______Address______</p><p>City______State____ Zip______</p><p>BEST NUMBER TO CONTACT YOU ______SECONDARY CONTACT </p><p>NUMBER______</p><p>Which method would you prefer to be contacted for appointment reminders (circle one) CALL TEXT EMAIL</p><p>Sex: M F Marital Status: S M W D SS#______</p><p>Email ______Would you like to receive newsletter and special offers via e-mail? Yes No</p><p>Currently Working? Yes No Employer ______</p><p>Occupation______Phone: ______</p><p>Emergency Contact______Relationship ______Phone:______</p><p>Referring Physician______Phone: ______</p><p>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______</p><p>Primary Insurance/ Responsible Party Secondary Insurance/ Other</p><p>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. </p><p>______Patient’s Signature (parent if minor) Date</p><p>______Clinic Representative Date </p>