State College Physical Therapy, Inc. dba Anaheim Hills Physical Therapy and Rehabilitation
|Thank you for choosing our office.
In order to serve you, we need the following information (Please print).
All information will be strictly confidential.
|Patient's Name: (Last,
|Marital Status: Single □ Married □ Widow □ Divorced □|
|Birth date: Age Sex Male □ Female □|
|Home Phone # Work Phone # Cell Phone #|
|Social Security #
Drivers License #
Name of Employer:
Employer Phone #
responsible for this account:
|If child, Parent's or Guardian's name:|
Relationship to patient
|Do you have medical insurance? Yes
□ No □
If yes, is it through your employer? Yes □ No □
|Insurance Co. Name and
|PPO □ HMO □ POS □ Medicare □ Medical □ Other □|
|If you do not have medical
insurance. How do you intend to pay? Cash □ Check □
|Who may we thank for referring
|I have read and fully understand
this office's Notice of Information Practices. I hereby consent to
the use and disclosure of my personal health information for purposes as
noted in this office's Notice of Information Practices. I
understand that I retain the right to restrict how my personal health
information is used or to revoke this consent by notifying the practice
in writing at any time.
Patient's, Parent's or Guardian's Signature Date