MEDICARE INTAKE FORMS
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If you have a Secondary
or Tertiary Insurance Company please provide us with that information in the
following spaces provided. We will need to make copies of the insurance card(s)
for your insurance folder. Secondary
Insurance Insurance
Company: _____________________________________________________ Insured
Name: _____________________________ Relation to Insured:_____________ ID/
Policy Number: _______________________Group Number: __________________ Mailing
Address: ________________________________________________________ City:
___________________________ State: ____________ Zip Code: ____________ Tertiary
Insurance Insurance
Company: _____________________________________________________ Insured
Name: _____________________________ Relation to Insured:_____________ ID/
Policy Number: _______________________Group Number: __________________ Mailing
Address: ________________________________________________________ City:
___________________________ State: ____________ Zip Code: ____________ Billing I
authorize the payment of benefits as determined by Medicare directly to the
Center for Physical Rehabilitation, Inc. I understand that I will be held responsible
for charges Medicare deems not to be reasonable and necessary. I understand that I will be notified of the
likelihood of Medicare denial and given the choice of being personally
responsible for any future charges incurred. Patient
Signature: ___________________________ Date: _______________________ Medical
Records For the purpose of collecting any outstanding balance regarding my
injury or illness, I authorize the Center for Physical Rehabilitation, Inc., to
release any medical or billing information requested. Signature:
_________________________________ Date: _______________________
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