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(520) 648-3132
155 W. Duval Rd. Green Valley, AZ 85614
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Progressive PT Green Valley
Patient Registration Forms
Registration Form
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Name:
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Last
Date of Birth:
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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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Do you have an Alternative Address (Seasonal)?
*
Yes
No
Alternative Address if Applicable (Seasonal):
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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)
*
Next
Emergency Contact Information
Name of emergency contact:
*
First
Last
Relationship to patient:
Friend or Relative Phone:
*
Next
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):
*
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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):
*
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Worker's Compensation Insurance Company Name:
*
Adjuster's Name:
Employer Name
*
Adjuster's Phone Number:
Claim Number:
*
Date of Injury:
*
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Auto Accident Insurance Company to be Billed:
*
Insurance Contact Name/Lawyer:
Insurance Contact Name/Lawyer Phone Number:
Claim Number:
Date of Injury:
*
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Next
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.
Email
Submit
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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