Introduction

This is to verify that _                                      has received and paid for the services provided in their plan of care while at Pursuit Physical Therapy.  This patient has paid in full out of pocket for the services provided and Pursuit Physical Therapy.  This form provides all of the necessary information for the patient to submit a claim to their insurance company for reimbursement or application to their deductible.  This form along with receipts should be provided to the patient’s insurance company.  PLEASE PROVIDE ANY PAYMENT OR REIMBURSEMENT DIRECTLY TO THE PATIENT.

Patient Information

Last Name:                                            First:                                     Middle:                             

Date of Birth:                                       Sex:                                                                                    

Address:                                                                                                                                           

City:                                                        State:                                      Zip:                                    

Marital Status:                                     Work Status:                                                                    

 

Insurance Information 

Insurance Provider:                                                                                                                       

Insured Name:                                                                        Relationship:                                

Policy or Group Number:                                                                                                              

Date of Birth:                                               Sex:                                                                            

Employer’s Name:                                                                                                                          

Insurance Plan or Program Name:                                                                                              

 

Provider Information

Facility Name:                                                                             

Address:                                                       

Facility Type:        Code =                  ____

Provider:                       License #:                                  

Tax ID #(EIN):                               National Provider #:

 

Services Provided

ICD- 10 Codes: 1.  _________  2.  __________  3.___________

(example)

Date of Service         CPT Code                   Units (minutes)       Cost/Unit       Charges

01/10/18                   97161                                      1                                              $150.00

01/17/18                    97140                                     2 (30)             $37.50            $75.00

01/17/18                    97110                                      2 (30)             $37.50            $75.00

01/27/18                   97140                                     2 (30)             $37.50            $75.00

01/27/18                   97110                                      2 (30)             $37.50            $75.00

02/27/18                   97140                                     2 (30)             $37.50            $75.00

02/27/18                   97110                                      2 (30)             $37.50            $75.00

TOTAL = $450.00

 

Signature

 

Pin It on Pinterest

Share This