Step 1 of 6

Which clinic is your scheduled evaluation?*

Name*

First Last

Patient Address*

Street Address City State / Province / Region ZIP / Postal Code

Patient DOB*

Gender*

Male

Female

Email*

Home Phone*

Cell Phone

Parent/Guardian Name (if patient under 18)

Primary Physician Name

Primary Physician Phone

Referring Physician Name

Referring Physician Phone

How did you hear about AZOPT?*

Please provide additional details about your referral so we can show our appreciation:

AZOPT prefers to keep its business “in the family” when possible. Are you involved in a business that could develop a relationship with AZOPT (i.e. graphic design, office supplies, printing, construction, etc.)?

Emergency Contacts

Primary Emergency Contact Name*

Primary Emergency Contact Relationship*

Primary Emergency Contact Phone*

Secondary Emergency Contact Name*

Secondary Emergency Contact Relationship*

Secondary Emergency Contact Phone*

Is this injury related to a car accident?*

Yes

If your injury is related to work or an auto accident, please provide our office with the details of your insurance coverage for this incident.

Primary Insurance Information

Insurance Company Name*

Subscriber Name*

Subscriber DOB*

ID Number

Group/Policy Number

Customer Service Phone Number

Located on back of insurance card

Secondary Insurance Information

Do you have secondary insurance?*

Yes

Insurance Company Name

Subscriber Name

Subscriber DOB

ID Number

Group/Policy Number

Customer Service Phone Number

Located on back of insurance card

Financial Policies

AZOPT is committed to providing the best possible care, and therefore, your clear understanding of our financial policy is important to our professional relationship. Please ask if you have questions about our fees, financial policy, or your financial responsibility.

AZOPT will request a photocopy of the front and back of your insurance identification card and driver’s license. Please update your card with any additional information your insurance company provides, which will facilitate the submission of claims on your behalf. It is your responsibility to inform us of any changes to your policy. We will bill your insurance company on your behalf as a courtesy.

Co-Payment/Co-Insurance
We must collect your carrier-designated co-pay at the time of service. Refusal to abide by this agreement may result in termination of your coverage.

AZOPT will calculate an estimated co-payment or co-insurance based on your insurance policy. This amount will be due at the time of each appointment.

Missed Appointments
Patients who do not show up for an appointment, or call to cancel with less than 24 hours’ notice have impacted other patient’s ability to obtain timely medical care. Therefore, subject to the individual patients’ insurance contract, we reserve the right to charge a $50.00 fee for no-show or same-day canceled appointments.

Returned Checks
If a check is used as your form of payment, and that check is returned due to insufficient funds or the payment has been stopped, you will be charged a $25.00 fee in addition to the amount of the check.

Insurance
We will gladly bill and accept payment from your health insurance plan. Any amounts not covered by your insurance carrier are your responsibility.

Communication between AZOPT and our patients help us succeed in providing the best care. Please advise us if your insurance company has pre-certification and/or prior authorization requirements and/or policy restrictions and limitations.

Payments
You are responsible for any amount not covered by your insurance carrier. All co-payments and deductible amounts are due at the time of service. For your convenience, we do accept all major credit cards, checks, money orders, and cash.

Patient or Guarantor

I have read and understand the above. I hereby authorize Arizona Orthopedic Physical Therapy, PLLC to submit claims to my insurance carrier. I hereby authorize direct payment of benefits, otherwise payable to me, to be made payable to Arizona Orthopedic Physical Therapy, PLLC. I understand I will be responsible for payment of any amounts not covered by my insurance carrier, including, but not limited to, co-payments and deductibles.

Signature*

Patient / Parent or Guardian Printed Name*

Date*

Authorization for the Release of Medical Records

I hereby authorize Arizona Orthopedic Physical Therapy, PLLC to release the medical record(s) of:*

Patient's DOB*

For the purpose of continued treatment and billing/re-assignment of benefits, this allows AZOPT to bill on your behalf, and for the payment to be sent directly to AZOPT, to:

Arizona Orthopedic Physical Therapy, PLLC
14557 W. Indian School Rd. #500
Goodyear, AZ 85395
Phone: 623-242-6908
Fax: 623-242-6909

Signature of Patient/Guardian:*

Printed Name*

Date*

Notice of Privacy Practices

Your name and signature below indicate that you have received a copy of and/or have been directed to the Notice of Privacy Practices by Arizona Orthopedic Physical Therapy, PLLC, on the date indicated. If you have any questions regarding the information set forth in AZOPT’s Notice of Privacy Practices, please do not hesitate to ask an AZOPT representative.

Signature of Patient/Guardian:*

Printed Name*

Date*

Photo Consent Release

I would like to extend permission to Arizona Orthopedic Physical Therapy, PLLC (AZOPT) to use my:

Name

Testimonial

Image/photograph

in publications and advertisements produced by or for AZOPT. I understand that these publications will also be placed on websites managed by AZOPT for public relations and advertising purposes. I understand that the publication may appear on the Internet, the publication may appear in print, electronic, or video media, and the publication may enable readers to identify me. I understand this consent is valid until I provide written notice stating otherwise.

Signature of Patient/Guardian:*

Printed Name*

Date*

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Emergency Contacts

Primary Insurance Information

Secondary Insurance Information

Patient History

Please check any and all medications you are currently taking:

Financial Policies

Authorization for the Release of Medical Records

Notice of Privacy Practices

Photo Consent Release

Form: New Patient Information

Emergency Contacts

Primary Insurance Information

Secondary Insurance Information

Patient History

Please check any and all medications you are currently taking:

Financial Policies

Authorization for the Release of Medical Records

Notice of Privacy Practices

Photo Consent Release