Rue & Primavera RehabilitationPhone (360) 279-8323
785 SE Bayshore Drive Ste 102FAX (360) 279-8772
Oak Harbor, WA 98277
Date: ______Email address (optional):______
Patient Name: ______
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Mailing Address: ______
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Home Phone: ______Cell Phone: ______Work Phone: ______
Occupation: ______Date of Birth ___/___/_____ Age: ___ Gender M_ F_ Married __ Single__
Person Responsible for your account (not your insurance company):______
Relationship to patient: ______Home Phone: ______Work Phone: ______
Mailing Address: ______
(If different from above)StreetCityZip
Place of Employment: ______Work Phone: ______
Was this an injury? Y__ N__ Date of Injury __/__/____ Job Related? Y__ N__
Claim Number: ______Claim Manager: ______Phone: ______
Employer at time of Injury: ______
Briefly explain how injury occurred: ______
Do you have medical insurance? Y_ N_ Primary Insurance Co.______
Primary Guarantor Name: ______
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Guarantor Date of Birth: __/__/____ SSN: ______
Patient ID Number: ______Group Number: ______
Secondary Insurance Co.______
Guarantor Name: ______Date of Birth: __/__/____
Patient Insurance ID Number: ______Group Number: ______
In case of an emergency, whom should we contact? ______
Phone? ______Relationship to patient: ______
Referring Doctor: ______Primary Care Physician: ______
I, the undersigned patient or patient’s representative, request admission to Rue and Primavera Rehabilitation for care and treatment. I certify that the information given is correct. I am aware that the practice of Rue and Primavera Rehabilitation is not an exact science and acknowledge that no guarantees or promises have been made as to the result of treatment of examination. I consent to and authorize the following:
RELEASE OF MEDICAL INFORMATION: I authorize Rue and Primavera Rehabilitation to release any information necessary to facilitate the processing of health care claims, and audit of payments relative to this care. I consent to the release of any information as needed to my referring and primary physician and to other health facilities or agencies as I direct or as required by law.
FINANCIAL AGREEMENT: I certify that the information given in applying for payment under government or private insurance is correct. I understand that any insurance benefit information given to me by any employee of Rue and Primavera Rehabilitation is based on general information that they have received from the insurance carrier and may not be specific to my insurance plan. I understand that I am financially responsible to Rue and Primavera Rehabilitation for charges that are not covered by my insurance carrier. Rue and Primavera reserve the right to impose reasonable financing and late payment charges as well as any attorney fees and expenses incurred in the collection of my account should it become delinquent. Financial responsibility may be waived if charity care is determined.
ASSIGNMENT OF BENEFITS: I hereby authorize payment directly to Rue and Primavera Rehabilitation, including major medical coverage.
MEDICARE CERTIFICATION: I certify that the information given by me in applying for payment under the Title XVIII of Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or related Medicare claim. I request that payment of authorized benefits be made on my behalf. (Consent applies only when applicable.)
PERSONAL VALUABLES: I acknowledge that Rue and Primavera Rehabilitation will not be held liable for the loss or damage of any money, jewelry, documents or other articles of value.
Patient or other legally responsible persons signatureDate
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Print Name if not PatientRelationship of legally responsible person to patient
In order to bill you insurance we must make a copy of your insurance card.