Therapist Name

Patient Name

Patient Street Address

Patient City

Patient State

Patient Zip Code

Patient Date of Birth

Patient Sex

Male Female

Primary Insurance Information

Insurance Company Name

Insurance Company Address

Insurance Company Phone

Policy ID #

Group Number

Is Patient the Insured?

Yes No

Insured Name

Insured Date of Birth

Is Condition Related To:

None Auto Employment Other

If Related to an Accident, Date of Accident

Secondary Insurance Information

Does the patient have secondary insurance?

Yes No

Secondary Insurance Company Name

Secondary Insurance Company Address

Secondary Insurance ID #

Secondary Insurance Group #

Secondary Insured Name

Secondary Insured Date of Birth

If Seen in a Hospital or Nursing Facility

Name of Facility

Date of Admission

Referring Provider Information

Name of Referring Provider

Referring Provider NPI

Date Last Seen by Referring Provider (if required)

Initial Treatment Date

Diagnosis Codes

Diagnosis Codes