INSURANCE VERIFICATION/INTAKE FORM: Name (as it appears on insurance card) * First Name Last Name Email * Phone Number (best number to reach you) Date of Birth * Insurance Provider * Please select your insurance provider. (Note: HMO and EPO plans not accepted) Aetna BlueCross BlueShield United HealthCare Cigna Self Pay Other If "other" insurance provider, please specify: Subscriber ID number: * (Please include any letters in your subscriber ID) How did you hear about PhysioStudio PT? * Doctor Friend/Coworker Family member or significant other Google ZocDoc Advertisement Social Media Other Gender Male Female Provider Telephone Number (on back of card) Condition to be treated: Do you have a PT prescription? Yes No Name of referring doctor or friend: Please respond to me by: Email Phone No Preference Additional comments: Thank you!
