FUSION PHYSICAL THERAPY PATIENT INFORMATION Full Name (Last - First) Gender DOB Age SSN Date: Home Address no PO Box City State Zip Code Marital Status Preferred Contact: Home Yes Work Yes Cell Yes Home Phone Work Phone Cell Phone Emergency Contact Phone Email Address Emergency Contact Patients Employer Occupation Employers Address or Retired from Spouse or Guardian Spouse or Guardian Phone Spouse/ Guardian DOB Referring Physician Diagnosis Surgeon Date of Surgery Describe Nature of Injury Attorney Date of Injury Auto Accident/ On the Job Injury: Yes No Date of Accident Attorney Phone Insurance Information Have you signed a waiver with your medical insurance carrier excluding coverage for your diagnosis? (Yes/No) Primary Insurance Policy Number ID Number Group Number Policy Holder Policy Holder Address Relationship to Patient Policy Holders Employer or Company Name Policy Holder DOB Secondary Insurance Policy Number ID Number_2 Group Number_2 Policy Holder_2 Policy Holder Address_2 Relationship to Patient_2 Policy Holders Employer or Company Name_2 Policy Holder DOB_2 Tertiary Insurance Policy Number ID Number_3 Group Number_3 Policy Holder_3 Policy Holder Address_3 Relationship to Patient_3 Policy Holders Employer or Company Name_3 Policy Holder DOB_3 I have been provided with the Notice of Privacy Practices and the Patient's Bill of Rights. Yes Information may be released to the following persons: (Person-1) I request the following restrictions on the use and/or disclosure of my Protected Health Information (Protected Health Information 1) Signature (Patient) Date: Fusion Physical Therapy accepts /denies The requested restrictions as stated above. Signature/Title Date:
