FOOTHILLS PHYSICAL THERAPY P.C. / C.O.C. PATIENT INFORMATION SHEET
PATIENT INFO INSURED/RESPONSIBLE PERSON INFO
PATIENT NAME___________________________________________________ NAME (if other than patient)_______________________________________
ADDRESS_________________________________________________________ ADDRESS______________________________________________________
CITY, ST & ZIP_____________________________________________________ CITY, ST & ZIP_________________________________________________
HOME TELEPHONE_________________________________________________ HOME TELEPHONE_____________________________________________
WORK TELEPHONE_______________________CELL #____________________ WORK TELEPHONE____________________________________________
Please *** the number you prefer us to call first if we need to contact you
DATE OF BIRTH___________________ SEX: M F Marital Status__________ DATE OF BIRTH___________________ SEX: M F Marital Status______
SOCIAL SECURITY #_________________________________________________ SOCIAL SECURITY #___________________________________________
EMPLOYER NAME___________________________________________________ EMPLOYER NAME______________________________________________
EMERGENCY CONTACT/TELEPHONE #_____________________________________________________________________RELATIONSHIP_______________
PRIMARY INSURANCE INFORMATION SECONDARY INSURANCE INFORMATION
INSURANCE NAME__________________________________________________ ____________________________________________________________
INSURANCE ADDRESS_______________________________________________ ____________________________________________________________
EMPLOYER NAME:__________________________________________________ ____________________________________________________________
ID/POLICY NUMBER_________________________________________________ ____________________________________________________________
GROUP NUMBER/NAME______________________________________________ ____________________________________________________________
POLICY HOLDER NAME______________________________________________ ____________________________________________________________
POLICY HOLDER DOB________________________________________________ ____________________________________________________________
WORK/AUTO CLAIM NAME OF CARRIER___________________________________________________CLAIM#______________________________________
CLAIM ADDRESS______________________________________________________________________________ PHONE #____________________________
ADJUSTER:___________________________________DATE OF INJURY:__________________ IN WHAT STATE DID ACCIDENT OCCUR?_________________
REFERRING PHYSICIAN'S NAME & PHONE #_____________________________________________________________________________________________
ACKNOWLEDGEMENT OF FINANCIAL/RECORD RESPONSIBILITY: This information is accurate and true to the best of my
knowledge. I understand that I am responsible and agree to pay for services rendered, including those provided that may be non-covered, reasonable attorney's fees and costs of collection in the event of default. I also hereby authorize both Foothills Physical Therapy, P.C. and Colorado Orthopedic Consultants, P.C. Therapists, Physicians and employees to release or obtain any information required to process insurance claims and manage my medical care. I authorize my insurance company to send payment directly to either Foothills Physical Therapy, P.C. or to Colorado Orthopedic Consultants P.C. whom represents Foothills Physical Therapy, P.C. in matters of billing.
SIGNATURE OF PATIENT/RESPONSIBLE PARTY:_________________________________________________ Date:___________