INFORMATION FORM

Provider Name: ______________________________________

Patient Information

Today’s Date: ___________ Date of Call: _________________________

New __ Existing __ Patient Initial Date: __________ Time: __________

Patient Name: ________________________________________ DOB: _____________ SS #: _____________________

Address: ____________________________________________ City, State, Zip: _________________________________

Home Telephone: _______________________ Work Telephone: __________________

Primary Care Provider: _____________________________ Diag Code:_________________

Referral Source: ________________________________

Family Composition:

Name: _____________________________________________ DOB: ___________ School/Educ: ____________________

____________________________________________ ___________ ____________________

_____________________________________ __________ _________________

_____________________________________ __________ _________________

_____________________________________ __________ _________________

Billing Information

Primary Insurance/Plan Name: __________________________Policy #: ______________________________ Group #: ______

Insured Person: ____________________________________ Relationship to Patient: _________________________

Employment: ______________________________________ Insured Person SS#:____________________________

Secondary Insurance/Plan Name: _______________________ Policy #: __________________________ Group #: ______

Additional Information : ___________________________________________________________________________________

ABS Services Eligibility/Authorization Information: In-Network___ OON ___

# of Visits Available: ________ Copay: __________ Parity Deductible: _________

Visits Authorized: ___________ Authorization #: _____________________ Date Range: ____________________

Active Since: ______________ Individual __ Family __ OTR Plan Due: _____________

Comment/Treatment Plan Address: