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:

Email:

Best Phone Number:

How did you hear about us?

Patient Address (Please Start Typing and then Click on your Autofill Address):

Date of Birth:

Emergency Contact:

Phone:

Primary Insurance:

Member ID

Secondary Insurance:

Member ID

Insurance Card Picture Uploads

Primary Insurance Card - Pictures of Front & Back

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Secondary Insurance Card - Pictures of Front & Back

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Patient’s condition related to:

Employment

Auto Accident

Other Accident

Previous PT in last year:

Primary Care Doctor:

Referring Doctor:

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?

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