Intake Form

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IntakeForm Form

Family Physical Therapy and Wellness, LLC

Patient Information:


Insurance Information:


Last Name:
Primary Insurance:
Secondary Insurance:

I authorize Family Physical Therapy and Wellness, LLC and its billing agency to bill my insurance company directly for the covered portion of charges, and I authorize payment of benefits directly to Family Physical Therapy and Wellness, LLC. I authorize Family Physical Therapy and Wellness, LLC and its billing agency to release medical or other information necessary to process this claim. I understand that I am responsible for my physical therapy charges, and I agree to pay my deductible, my co-insurance or co-payment, and any charges not reimbursed by my insurance carrier. I understand that some insurance companies require medical or administrative pre-authorization for treatment, or have reimbursement limits on physical therapy treatments. I understand I am responsible for knowing and meeting the requirements for my insurance plan.