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Progressive PT Green Valley
Patient Registration Forms
Registration Form

- Step 1 of 4

Please Do Not Print This Form

Name: *

First

Middle

Last

Date of Birth: *

SSN:

Gender: *

Male
Female
Other

Marital Status (Select one)

Single
Married
Divorced
Separated
Widowed

Title:

Mr.
Mrs.
Miss
Ms.
Other

If other, please enter below:

Permanent Mailing Address for Billing: *

Address Line 1

Address Line 2

City

State

Zip Code

Do you have an Alternative Address (Seasonal)? *

Yes
No

Alternative Address if Applicable (Seasonal):

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone:

Cell Phone:

Work Phone:

Email:

Appointment reminder preference (check one): *

Home Phone
Cell Phone
Text
Email

Cell Phone Provider: *

Verizon
T-Mobile
AT&T
Other

Name of Cell Phone Provider (Example: Boost Mobile / MetroPCS / Cricket Wireless) *

Emergency Contact Information

Name of emergency contact: *

First

Last

Relationship to patient:

Friend or Relative Phone: *

Insurance Information

Insurance Portion Must Be Completed For Accuracy

Who will Progressive Physical Therapy be billing? *

Insurance (e.g. Medicare, BCBS, UHC, Tricare, VA)
Worker's Compensation
Auto Accident
Self Pay

Name of Primary Insurance: *

Member Number of Primary Insurance *

Patient's relationship to policy holder: *

Self
Spouse
Child
Other

Name of Policy Holder (If not self): *

Date of Birth of Policy Holder (If not self): *

Do you have a secondary or supplement insruance? *

Yes
No

Name of Secondary or Supplemental Insurance: *

Member Number of Secondary or Supplemental Insurance *

Patient's relationship to Supplemental Policy holder: *

Self
Spouse
Child
Other

Name of Secondary Policy Holder (If not self): *

Date of Birth of Secondary Policy Holder (If not self): *

Worker's Compensation Insurance Company Name: *

Adjuster's Name:

Employer Name *

Adjuster's Phone Number:

Claim Number: *

Date of Injury: *

Auto Accident Insurance Company to be Billed: *

Insurance Contact Name/Lawyer:

Insurance Contact Name/Lawyer Phone Number:

Claim Number:

Date of Injury: *

Electronic Signature *

The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the provider. I understand that I am financially responsible for any balance. I also authorize Progressive Physical Therapy or insurance company to release any information required to process claims.

Patient/Guardian Name:

Date *

Acceptance *

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

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Hours of Operation

Monday - Friday

8:00am - 4:30pm

Office Location

Progressive
Physical Therapy

155 W. Duval Rd.
Green Valley, AZ 85614
Phone: (520) 648-3132
FAX: (520) 648-1861

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Registration Form

Please Do Not Print This Form

Emergency Contact Information

Insurance Information

Insurance Portion Must Be Completed For Accuracy

Hours of Operation

Monday - Friday

8:00am - 4:30pm

Office Location

ProgressivePhysical Therapy

Are you ready to start feeling better?

Call Today: (520) 648-3132

Patient Resources

Quick Links

Progressive
Physical Therapy