1599 North Hermitage Road, Hermitage, PA 16148

(724) 962-7920

Name: _____________________________________
(First)

_____________________________________
(Last)

152 Waugh Avenue, New Wilmington, PA 16142

(724) 946-3313

Marital Status:
Single

Married

Divorce

Widowed

Spouse: ________________________________________

Address: ___________________________________
(Street)

(Guardian of minor/dependent patient)

Address: _______________________________________
(Street)

___________________________________
(City, State Zip)

________________________________________
(City, State Zip)

Date of Birth: ___________________________________

Phone: _____________________________________

(mm/dd/yyyy)

(Home)

Employer: ______________________________________
____________________________________________

(Work)
____________________________________________

Primary Insurance:

(Cell)

Medicare/HMO: Please provide copy of card

Email: _____________________________________

Group Health: Please provide copy of card

Policy Holder (If other than patient):
Name: ___________________________________
Address: _________________________________
Date of Birth: _____________________________
Relationship to Patient: ______________________

Soc. Security: _______________________________

Date of Birth: _______________________________
(mm/dd/yyyy)

Age: _______________________________________
Gender:

Male

Female

Employer: __________________________________
Address: ___________________________________
(Street)
__________________________________________
(City, State Zip)

*** EMERGENCY CONTACT ***

Name: ______________________________________
Phone: _____________________________________
Relationship: ________________________________
Family Physician: ____________________________
Ambulance Service: ___________________________

Workers Comp:
Employer: ________________________________
Address: _________________________________
Phone: ___________________________________
Insurance Carrier: __________________________
Date of Injury: _____________________________
Claim #: __________________________________
Auto:
Insurance Company: ________________________
Address: _________________________________
Phone: ___________________________________
Date of Accident: __________________________
Claim #: __________________________________
Other: ___________________________________
*** How you heard about us ***
Radio
Television
Newspaper
Internet
Other: _____________________________________

I hereby authorize Penn-Ohio Rehabilitation, PC to provide medical treatment myself/my dependent.

I hereby authorize Penn-Ohio Rehabilitation, PC to release to my insurance carrier and its agents any information needed to determine benefits and process claims for
services provided to me by Penn-Ohio Rehabilitation, PC and /or required by law. I request that payment of benefits, including any government benefits
(Medicare/Medigap), be sent to Penn-Ohio Rehabilitation, PC for services furnished to me by that provider. I understand and agree that I will be responsible for any
portion of payment as determined by my insurance policy. I certify that I have provided true and accurate information to the best of my knowledge.

Signature: _________________________________________________ Date: _______________________