Common Contracts

Patient Agreement

May 2nd, 2012

• Filed
  May 2nd, 2012

Dr. REP: Date of Surgery: Procedure: UPIN# Primary Ins. Co: Phone: Address: City: State: Zip: ID/Policy#: Group#: Insured:Relationship to Insured: ❑ Self ❑ Spouse ❑ Child Patient: DOB: SS#: Address: City: State: Zip: Home Phone:Cell Phone: Secondary Ins. Co: Phone: Address: City: State: Zip: ID/Policy#: Group#: WC PATIENTS ONLY Employer Name: Insured: Address: Relationship to Insured: ❑ Self ❑ Spouse ❑ Child City: State: Zip: Claim#(W/C): DOI: Office Phone: Adjuster: Delivery Date: Rented From: to Stop charge date 7 day minimum rental. Overnight rental is considered as a full day.$ per day. CPM Model: Serial#: Thermotek Model: Serial#: Sale Items (Subject to applicable sales tax):❑Iceman ❑Contrast ❑TSLO Back Brace ❑Compression Therapy (Nano) ❑CPM Shoulder❑Shldr/Knee/Back/Ankle Cold Pad ❑ LSO Back Brace ❑CPM Soft Goods ❑CPM Knee❑Back Wrap ❑Cervical/Vista Collar ❑OTS Knee Braces ❑CPM Other❑Shldr/Knee/Back/Ankle Sterile ❑TENS/E-STIM ❑Custom Knee Brace ❑ ❑Pain Control Device ❑Raised