CENA REHAB CENTER INITIAL PATIENT INTAKE FORM

Thank you for choosing CENA Rehab Center. Please fill in the information below.

Patient Information

Today Date * +

Time *

Date of Accident? * +

First Name *

Middle Initial

Last Name *

Social Security # *

Birth Date * +

Address *

Phone Number *

City *

State *

Zip Code *

Emergency Contact Name *

Relationship to you *

Phone Number *

Email *

Referred Physician *

Ritecare

Dr. Idalys Morono

Other

INSURANCE / ATTORNEY INFORMATION

AUTO INSURANCE CARRIER *

ADJUSTER'S NAME

POLICY # *

CLAIM #

PRIMARY HOLDER'S NAME *

LISTED DRIVER? *

YES

NO

UNKNOWN

ATTORNEY'S NAME

ATTORNEY'S NUMBER

I AUTHORIZE CENA REHAB CENTERTO RECEIVE AND SEND INFORMATION, TO MY INSURANCE CARRIER. I HEREBY AUTHORIZE PAYMENTS FROM MY INSURANCE COMPANY TO BE DIRECTED TO CENA REHAB CENTER. IF MY BENEFITS ARE EXHAUSTED DUE TO PRIOR HOSPITAL/ER/AMBULANCE/ETC I WILL NOTIFY THE BILLING DEPT OF CENA REHAB CENTER/ I AM RESPONSIBLE FOR ALL THERAPY BILLS BILLED BY CENA REHAB CENTER FOR SERVICES RENDERED TO ME BEYOND MY COVERAGE ALLOWABLE.

I UNDERSTAND FAILURE TO DO SO WILL PUT ME IN CHARGE/PERSONALLY RESPONSIBLE FOR ALL PAYMENT MATTERS FOR THE SERVICES CONDUCTED AT CENA REHAB CENTER. IF FOR ANY REASON(S) I DO NOT PAYFOR MY SERVICES I AUTHORIZE CENA REHAB CENTER TO FILE SUIT AGAINST ME AND I AGREE TO PAY ATTORNEY FEES AND CHARGES.

PATIENT'S SIGNATURE *

clear