At Alliance Physical Therapy we provide 24/7 access to online appointments, with most of the requests scheduled in less than 48 hours. We are able to serve the Northern VA and DC region.

1. Last Name __________________________________ First ____________________________________ Middle______________________
Address ________________________________________________________________________________________________________
City_________________________________________________________ State ________________ Zip Code ______________________
Home Phone _____________________________ Cell Phone ___________________________ Work Phone ________________________
Soc. Sec. _______________________________ D.O.B _____/______/_____ Age ______ Sex ______Marital Status___________________
Email Address _________________________________________ Referring Physician___________________________________________
Spouse Name _____________________________________________ Social Security #_________________________________________
Phone #_______________________________________________ Spouse Employer ___________________________________________
IN CASE OF EMERGENCY (PERSON NOT RESIDING WITH PATIENT)
Name _________________________________________________ Relationship to Patient ___________________________________
Phone # _______________________________________________
 HEALTH INSURANCE
PrimaryInsurance ___________________________________________________________Phone ________________________________
Policy # ________________________________________ Group# __________________Subscriber’s Name_________________________
Relationship to Subscriber _______________________________Social Security # _______________________D.O.B._________________
Secondary Insurance____________________________________________________ Phone____________________________________
Policy #_____________________________Subscriber’s Name________________________ Relationship to Subscriber_______________
Were you involved in an accident: ____Yes____ No Date of Injury: _____/_____/_____
Please circle one Auto / WC / Miscellaneous Which State: ___VA____DC____ MD or _____ Other___________
 WORKERS COMPENSATION OR PERSONAL INJURY INFORMATION
Insurance Name_____________________________________________ Phone#: __________________________________
Adjustor/ Case Manager Name: ________________________________________Phone #: _________________________
Claim #: _____________________________________ Date ofInjury: ___________________________________________
3
rd
PartyInsurance Name:____________________________________Phone #:__________________________________
Adjustor/ Case Manager Name: ____________________________________Phone #: ______________________________
Claim #:_____________________________________________________________________________________________
 AUTO INSURANCE/ MED PAY
AutoIns./Medpay Company: ____________________________________________________ Phone #: ___________________________
OR Auto Ins./Lien Company: _______________________________________________________ Phone #: ________________________
Claim Number: ____________________________________ Name of Adjuster: ______________________________________________
Adjuster Phone #: _____________________________________ Date ofInjury: ____________________________________
ATTORNEY INFORMATION
Name: ______________________________________________ Phone #___________________________ Fax#_____________________
Please remember that Insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a sub stitute for payment. Some companies may pay
fixed allowances for certain procedures; they sometimes ref er to as “Reasonable and customary fees.” We do not accept this as payment in full (unless otherwise restricted by
law or agreement we may have with your insurer). Also some of the insurance companies only pay a percentage of the charge. It is your responsibility to pay any deductible
amount, co-insurance or any other balance not paid for by your insurance. IN ORDER TO CONTROL YOUR COST OF BILLINGS, WE DO REQUEST THAT OUR CHARGE FOR OFFICE
VISITS BE PAID AT THE INITIATION OF EACH VISIT. In the event the account is turned over for collections, the collection fees and /or legal fees, including attorney fees, s hall be
your responsibility. I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled, Medicare, private insurance and other health
plans to the facility listed in the top header of this page. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered
as valid as an original. I hereby authorize said assignee to releas e all information necessary to secure the payment, via fax transmittal or hard copy.
Patient/Parent or Legal Guardian Signature ____________________________________________ Date ________________________
How did you hear about us?
__________________________________________________________________
PAYMENT OPTIONS (Please check mark the payment option you are using):
PATIENT INFORMATION