Form

Primary Medical Insurance

Secondry Medical Insurance


Ins. Co. Name
Policy Holder Name:
Policy Holder's Date of Birth:
Policy Holder Social Security #:
Patient Relationship to Policy Holder:


Ins. Co. Name
Policy Holder Name:
Policy Holder's Date of Birth:
Policy Holder Social Security #:
Patient Relationship to Policy Holder:

I certify that I have read and agree to Pain Therapy Associates' payment policy. I am eligible for the insurance indicated on this form, and I understand that payment is my responsibility regardless of insurance coverage. I hereby assign to PTA all money to which I am entitled for medical expenses related to the services performed from time to time by PTA, but not to exceed my indebtedness to PTA. I authorize PTA to release any medical information to my insurance carrier or third-party payer to facilitate the processing of my insurance claims. I understand that failure to pay outstanding balances within 90 days of notification of the amount due will result in submission to an outside collection agency. A $35.00 returned check fee will be charged for checks returned due to insufficient funds.

I choose to receive communications from PTA by text or email at the number or address stated above, including but not limited to communications about appointments, feedback, treatment, and payment. I understand that such emails and texts may not be secure, and there is a risk that they may be read by a third party. Comments submitted on SurveyS may be anonymously shared on the PTA public website.

MEDICARE BENEFICIARIES: I request that payment of authorized Medicare benefits be made to PTA. I authorize any holder of medical information about me to release to CMS and its agents any information needed to determine these benefits or the benefits payable for related services.

	Please list all non-prescription medications that you are taking.
1.
2.
3.
4.
5.
6.

	Not at all	Several days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things. such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead or hurting yourself in some way

Patient Registration Form

Patient Information:

Responsible Party- If the patient is a minor (under the age Of 18), the parent or guardian bringing the patient in will be listed as the guarantor:

Additional Information (PLEASE FILL OUT ALL SECTIONS BELOW):

Primary Medical Insurance

Secondry Medical Insurance

I have reviewed a copy of Pain Therapy Associates Privacy Notice.

Medical History Form

Primary Care information

Past/Current Medical History:

Health Care Consent

Notice Of Privacy Practices Aknowledgement

Phone Message and Contact Authorization

Acknowledgement of Receipt of Pain Therapy Associates Financial Contract

Pain Therapy Associates

FINANCIAL CONTRACT

Acknowledgement of Receipt of Pain Therapy Associates Financial Contract

Medicare:

BPO:

PATIENT HEALTH QUESTIONNAIRE-9 (PHQ-9)

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