Dreher Physical Therapy

Admission Billing Information

A doctor's prescription is required if you have Medicare or Blue Cross Blue Shield for your insurance. Please call your doctor and bring it in on your first visit.

Patient’s first & last name

Best phone number

How did you hear about us?

Address / City / State / Zip Code

Date of birth

Emergency contact first & last name

Emergency contact's phone

Primary insurance

Member ID

Secondary insurance

Member ID

Insurance card picture uploads

Primary insurance card - Pictures of front & back

Select Files

Secondary insurance card - Pictures of front & back

Select Files

Patient’s condition related to

Employment

Auto Accident

Other Accident

Previous PT in last year

Primary care doctor

Primary care doctor's phone

Primary care doctor's fax

Referring doctor

Referring doctor's phone

Referring doctor's fax

Any other related information

*It is the patient's responsibility to confirm we are in network with your insurance.

Please call to confirm with your insurance company.

You will also need to ask your insurance:

Do you have a copay or co-insurance? If so, how much?
Does your deductible apply?
How many PT visits do you have through insurance?
Does your insurance run on a calendar year?
Is an authorization or referral required for physical therapy?

If you were getting home health / visiting nurse services prior to coming to us, please confirm that the agency has done a full agency discharge and let us know the name of that agency.

Thank you for submitting your Admission / Billing information!

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