OFFICE IN SCREENING
Do you have any of the following?
PATIENT INFORMATION
EMERGENCY INFORMATION
In case of an emergency who should be notified?
Patient Initial Intake Form
How severe is the pain (0=none, 10=severe pain)
Please list your medications, dose and frequency (please include any vitamins or over the counter medications)
ASSIGNMENT OF BENEFITS As a medical provider, our relationship is with you, not your insurance company. As a courtesy to our patients, we are willing to submit your claims to your insurance company for reimbursement, providing your insurance company allows us to do so. However, all charges are ultimately your responsibility from the first date services are rendered. To this regard, you are responsible for your co-payments, deductible and any portion of your claims your insurance company chooses to exclude from payment. If you have any questions regarding the above or any uncertainty regarding your insurance coverage, please do not hesitate to ask us. We are here to assist you.
PRIMARY INSURANCE INFORMATION
SECONDARY INSURANCE INFORMATION
I HEREBY STATE THAT THE INJURY WHICH I AM RECEIVING TREATMENT FOR IS NOT DUE TO A WORKMAN’S COMPENSATION CASE OR NO FAULT ACCIDENT.
IT IS THE PATIENTS RESPONSIBILITY TO INFORM US IF YOUR INSURANCE CARRIER CHANGES DURING YOUR TREATMENT HERE.
IF YOU FAIL TO INFORM US YOU WILL BE HELD RESPONSIBLE FOR ALL CHARGES NOT COVERED.
The US Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue
Washington, D.C. 20201
Privacy Officer
William J. Schwarz, P.T., P.C.
5700 Merrick Road
Massapequa, NY 11758