INFORMATION FORM

 

Provider Name: ______________________________________    

             

Patient Information

 

Today’s Date: ___________                                                       Date of Call: _________________________

New __  Existing __  Patient                                                       Initial Date: __________ Time: __________

 

Patient Name: ________________________________________   DOB: _____________    SS #: _____________________

 

Address: ____________________________________________  City, State, Zip: _________________________________

 

Home Telephone: _______________________                                    Work Telephone: __________________

 

Primary Care Provider: _____________________________              Diag Code:_________________

 

Referral Source: ________________________________ 

 

Family Composition:

 

Name: _____________________________________________     DOB: ___________  School/Educ: ____________________

 

            ____________________________________________                  ___________                        ____________________

 

         _____________________________________                __________                  _________________

 

         _____________________________________                __________                  _________________

 

         _____________________________________                __________                  _________________

 

 

Billing Information

 

Primary Insurance/Plan Name: __________________________Policy #: ______________________________ Group #: ______

 

Insured Person: ____________________________________  Relationship to Patient: _________________________

 

Employment: ______________________________________   Insured Person SS#:____________________________

 

Secondary Insurance/Plan Name: _______________________   Policy #: __________________________  Group #: ______

 

Additional Information : ___________________________________________________________________________________

           

 

ABS Services Eligibility/Authorization Information:    In-Network___  OON ___

 

# of Visits Available: ________               Copay: __________       Parity                           Deductible: _________

 

Visits Authorized: ___________              Authorization #: _____________________   Date Range: ____________________

 

Active Since:  ______________                          Individual __  Family __                                        OTR Plan Due: _____________

 

Comment/Treatment Plan Address: