Insurance Information Form - Allcare Therapy Services, LLC

INSURANCE INFORMATION

As a courtesy we will bill your primary insurance carrier if you provide ALL necessary
information (such as insurance cards with their CORRECT billing address and REFERRALS).
Co-pays are collected for each visit at the time of service.

Statement of Financial Responsibility

I understand my insurance carrier may not approve or reimburse my medical services in full due
to usual and customary rates, benefit exclusions, coverage limits, lack of authorization, or
medical necessity. I understand I am responsible for fees not paid in full, co-payments, and
policy deductibles and co-insurance.

PRIMARY INSURANCE

Insurance Name:

Claims Address:

Policyholder Name:

Policyholder DOB:

Marital Status:

Policyholder Social Security #:

Policyholder ID #:

Patient ID #:

Group #:

Your First Name:

HIPPA Required Field.

Your Last Name:

HIPPA Required Field.

Your Email

HIPPA Required Field.

Signature of Legal Guardian:

For billing purposes we require this form to be fully completed. We reserve the right to reschedule
any appointments due to incomplete forms or tardiness. Thank you for your cooperation.