Forms

A pdf of the Verification Form may be downloaded here:

Verification Form

Verification of Insurance/Benefits
  • Verification of benefits is not a guarantee of payment and financial responsibility is subject to change.
    0
  • Yearly Deductible $*Your primary insurance carrier had verified you have a yearly deductible of
    1
  • Deductible Amount met $*Amount of deductible met to date
    2
  • Coverage %*After your deductible has been satisfied, your insurance carrier estimates your therapeutic benefits are covered at
    3
  • Estimated Responsibility per visit $*You have an estimated responsibility of
    4
  • Estimated Responsibility per visit %*You have an estimated responsibility of
    5
  • Limitations*Your insurance company has advised us that your policy has the following limnitations
    6
  • In order to ensure that we are filing the correct insurance please answer the following questions
    7
  • Injury related to auto accident?*Y or N
    Yes
    No
    8
  • Do you have legal representation (attorney)?*Y or N
    Yes
    No
    10
  • Do you have a letter of exhaustion from your Auto Carrier*Y or N
    Yes
    No
    15
  • Do you have medical / health insurance?*Y or N
    Yes
    No
    17
  • Injury related to a work accident?*Y or N
    Yes
    No
    22
  • Have you received therapy for the same illness/injury in the last year?*Y or N
    Yes
    No
    25
  • Are you (or have you) currently receiving any type of Home Health services?*Y or N
    Yes
    No
    28
  • Referring Physician*Name of physician who referred you for therapy
    31
  • Phone*
    32
  • Primary Care Physician*Name of primary care physician
    33
  • Phone*
    34
  • Benefits that we have received from your insurance carrier at the time of service are not a guarantee of benefits. The patient, legal guardian or parent (if the patient is under 18 years old) will be responsible for the co-payment and the deductible at the time of service.
    35
  • Patient Name*full name
    36
  • Guardian*full name
    37
  • Date*Today's Date
    39
  • Please click the Submit button when you are done.
    40
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