Insurance Form – Balanced Physical Therapy

Patient Information

Patient's Name

Date of Birth

Insurance Information

Primary Insurance Carrier

Secondary Insurance Carrier

Provider Info Phone

Member ID

Insured Person's Information (Fill out this portion if the insured person is NOT yourself)

Insured's Name

Date of Birth

Mailing Address

City & Zip Code

SSN

Home Phone

Cell/Alternate Phone

Occupation

Employer

Work Phone

Auto Insurance Information (Fill out this portion if an auto insurance will be paying for the services)

Auto Insurance Carrier

Claim

Claim Adjuster's Name

Adjuster's Phone

Signature

Date

Contact Information