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Patient Information Form
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(Please Print)
Acct#_________________ Payor: Self ____ Group Ins ___ Work Comp ____ Other ___
Name:_____________________________________________________________________ (Last) (First) (Middle Initial
Address:___________________________________________ City / State / Zip:___________
__________________________________________________________________________
Phone:____________________ Birth date: (mo/da/yr)_______________ Age:______
Sex: Male___ Female ___ Marital Status S M D W SSN: ________________
May I leave phone messages when necessary: Yes___ No ___
EMPLOYMENT INFORMATION Phone:__________________ Fax:________________
Name:_____________________________________________________________________
Address:__________________________________________________________________ (City) (State) (Zip)
Occupation: ________________________________________________________________
PRIMARY INSURANCE CARRIER Phone: _______________ Fax:______________
Company:__________________________________________________________________
Address:___________________________________________________________________ (City) (State) (Zip)
Insured (Name) _____________________________________________________________
(Relationship)_________________________Group / Claim#:_________________________
REFERRING PHYSICIAN / AGENCY Phone: _______________ Fax:______________
Company:_____________________________________________ Reports: Yes No
Address:___________________________________________________________________ (City) (State) (Zip)
Type of Evaluation:___________________________________________________________
Diagnosis:________________________________________________________________
INJURY INFORMATION
Check One: Work Related ____ Auto Accident ____ Other____
Date of current Illness/Injury:________________________ Date Stopped Working __________
Brief Description of Accident:_________________________________________________________________
_________________________________________________________________________
EMERGENCY NOTIFICATION / NEAREST RELATIVE
Name:_________________________________________Relationship:________________
Address:_______________________________________Phone;______________________
RELEASE OF AUTHORIZATION / ASSIGNMENT OF BENEFITS
I authorize Midwest Rehabilitation Inc. To release orally or in writing to my health insurance company, HMO, utilization review group affiliation: and to referring, family or any physician all information requested concerning myself or my dependents for treatment, payment or healthcare operations.
In the case of Workers Compensation, I authorize Midwest Rehabilitation Inc. To release orally or in writing to my employer, its insurance carrier, claims administrator, rehabilitation/ medical management consultant, and attorneys all information requested concerning myself for treatment, payment or health care operations. If the status of this claim should change and workers compensation is no longer responsible for the charges incurred for the injury, I will notify Midwest Rehabilitation Inc. Immediately.
I agree to pay ant additional charges to collect my unpaid bills, including but not limited to, reasonable attorney fees, and court costs and collection agency fees.
I authorize my insurance carrier to pay to Midwest Rehabilitation Inc. The benefits due me or my dependents for services rendered..
SIGNED______________________________________________ DATE_______________
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