Fillable Patient Information Form (Haverford College in Pennsylvania)

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Patient Information Form (Haverford College in Pennsylvania)

On average this form takes 18 minutes to complete

The Patient Information Form (Haverford College in Pennsylvania) form is 1 page long and contains:

  • 0 signatures
  • 41 check-boxes
  • 51 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Haverford College in Pennsylvania

BROWSE HAVERFORD COLLEGE IN PENNSYLVANIA FORMS

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Patient Information Form
Patient Demographic Information
*Last Name
*First Name
*Middle Initial
Address
City
State
Zip Code
*Appointment Reminder Contact Method
☐
Text
☐
Mobile
☐
Email
☐
Home Phone
(Choose method of choice)
☐
No Appointment Reminder
*Email Address
☐
Declined Email
☐
No Email
*Date of Birth
SSN
*Sex
☐
F
☐
M
Status
☐
Single
☐
Married
☐
Other
Employer Information
Employer
Employment Status
☐
FT
☐
PT
☐
None
☐
Retired
☐
Student
Address
City
State
Zip Code
Work Phone
Occupation
Emergency Contact Information
Contact Name
Phone
Relationship
Physician Information
Referring Physician
Phone
Script Date
Additional Questions
Injury /Onset Date
Post‐Surgical
☐
Yes
☐
No
Surgery Date
Body Part/DX
Work Related
☐
Yes
☐
No
Accident Related
☐
Yes
☐
No
Auto Related
☐
Yes
☐
No
Attorney Involved
☐
Yes
☐
No
Adjuster/Nurse Cases Mgr.
Phone
Attorney
Phone
Have you had prior Therapy this year? (PT/OT/SP/Chiro)
☐
Yes
☐
No
How did you hear about us?
Medicare ONLY! Additional Questions
If Medicare, are you currently Receiving Home Health Services?
☐
Yes
☐
No
If YES, Name of Agency
If discharged what is last date of service?
Are you currently residing in a Skilled Nursing Facility? If Yes, Name of facility
Primary Insurance Section
Secondary Insurance Section
*Insurance/Plan
*Insurance/Plan
*Policy ID #
*Policy ID #
*Group #
*Group #
*Insurance Phone
*Insurance Phone
Are you the policy holder?
☐
Yes
☐
No
If no, continue
Are you the policy holder?
☐
Yes
☐
No
If no, continue
Card Holder Name
DOB
Card Holder Name
DOB
Patient Relationship to Policy holder
☐
Self
☐
Spouse
☐
Child
Patient Relationship to Policy holder
☐
Self
☐
Spouse
☐
Child
Patient, Please initial here if the above information is correct and complete
Date
***Office Staff use ONLY (below)***
Intake Completed by
Date
*Date Eval Scheduled
Registered by
Date
Acct #
Patient Service Specialist will initial next to each task below once completed.
Billing Disclosure added
in RT Comments
☐
Verified
DL/Photo ID
☐
Consent to receive calls and/or text messages, reviewed with patient. If patient agrees and
signed consent, is text enabled box checked in RT?
☐
Last updated 8/24/18
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Patient Information Form (Haverford College in Pennsylvania)

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Completed 21 August 2020

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