Preview Patient Information Sheet

Patient name: __________________________________________________________________

LAST FIRST MIDDLE

Date of Birth: __________ Age: _______________________ (please circle :) Female Male

Address: ________________________________________Responsible Party SS#:____________

Required If patient a minor and/or full-time student

City: ___________________________________ State: _____ Zip: _________________________

Home Phone # ____________________________ Work/ Cell Phone # ________________________

Patient SS# _____________________________ Drivers License #________________________

Employer:_______________________________ Occupation: ____________________________

Employer’s City: __________________________ State: _________ Zip: ________________

Marital Status (please circle): Married Single Divorced Widowed

Name of Spouse: ___________________________________ Spouse’s Work Phone # __________________________

Primary Insurance Company: ___________________ Name of Insured:________________________

Relationship to Insured: _______________________ Insured’s DOB: _________________________

Insured SS # ____________ Group Name/Number: ________________ Policy #_________________

Secondary Ins: ______________________________ Name of Insured: _______________________

SEVEN OAKS WILL ONLY BILL 2ND IF WE ARE CONTRACTED PROVIDER

SS# / Policy # of insured: ________________________ Insured’s DOB: _________________________

Referring Physician: ____________________ Phone #: ____________ Fax #: ___________________

Date of Injury/Start of Symptoms: ________ Area of Body to be treated _______________________

INSURANCE REQUIRES THE DATE, MONTH AND YEAR (WILL NOT PAY WITHOUT THIS INFORMATION)

Type of Accident/Illness: __________________________ No ___ Yes _______________________

(Home? Work? Sports? Auto?) Do you have an Atty? If so, Name & Tel number

I DO HEREBY ASSIGN all insurance benets to be paid directly to Seven Oaks Rehabilitation & Fitness Center for all medical services provided to

me. I also acknowledge that I am personally liable for all charges incurred by me for treatment services provided me by Seven Oaks Rehabilitation

& Fitness Center. I further authorize Seven Oaks Rehabilitation & Fitness Center to release information required regarding the course of my

treaunent, for the purpose of evaluating and administering claims for benets. I understand I am responsible for services not cover by my insurance,

i.e. benets exhausted or do not meet criteria of medical necessity per your pJan’s guidelines. I have been informed of & agree to abide by the

cancellation policy. ANY PERSONAL BALANCE 30 DAYS OR MORE PAST DUE MAY BE SUBJECT TO A 1.5% FINANCE CHARGE.

_____________________________________ ______________

SIGNATURE OF PATIENT / PARENT IF MINOR DATE

____________________________________ ______________

SIGNATURE OF RESPONSIBLE PARTY / PARENT IF PATIENT IS FT STUDENT DATE

________________________________________________________________

PATIENT INFORMATION SHEET ACCT # PT

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