(1) Patient Information: (Full name as it appears on your Insurance Card)
(2) Patient’s Doctor: Please list your referring doctor and/or your Primary Care Physician
(3) Auto or NonWork Accident Claim- Please add attorney information if applicable
A) I understand that I and my attorney must agree to the terms of Atlas Physical Therapy’s “Letter of Protection/Lien” in order for a liability claim to be considered as a payment source.
B) I understand that if I am using my personal car insurance I must assign payment benefits to Atlas Physical Therapy and be prepared to pay should I exhaust the medical funds:
(4) Clinic Policies:
Please Intial Below