Allied Rehab Discharge Eval Packet

Allied Rehab Discharge

Patient Information

First Name(Required)

Last Name(Required)

Email(Required)

Date of Birth(Required)

Social Security(Required)

Sex(Required)

Race

Other

Ethnicity(Required)

Primary Language(Required)

Primary Phone

Secondary Phone

Work

Address(Required)

Street Address Address Line 2 City State ZIP Code

Referring Physician(Required)

Phone

Primary Care Physician(Required)

Phone

Primary Insurance Information

Name of Insurance Company

Policy Number

Group Number

Are you the policy holder

Name of Policy Holder

First Last

Relationship to Patient

Date of Birth

Social Security

Phone

Address

Street Address Address Line 2 City State ZIP Code

Employer

Secondary Insurance Information

Do you have a secondary insurance policy

Name of Insurance Company

Policy Number

Group Number

Are you the policy holder

Name of Policy Holder

First Last

Relationship to Patient

Date of Birth

Social Security

Phone

Address

Street Address Address Line 2 City State ZIP Code

Employer

Work / Auto Related Injury

Is this the result of an accident

Date of Injury/Accident:

Insurance Carrier

Contact Name

First Last

Phone

Address

Street Address Address Line 2 City State ZIP Code

Claim Number

Insurance ID Number

State where injury occurred

Employer Name

Employer Address

Street Address Address Line 2 City State ZIP Code

Contact Name

First Last

Phone

Address where injury occurred

Job Title

Job Duties

Adjuster Handling Claim Name

First Last

Adjuster Handling Claim Phone

Attorney Handling Claim Name

First Last

Attorney Handling Claim Phone

To ensure we are providing quality care, we need information from you and need to provide you with information about our practice policies. Below are links to our practice policies. Please click on each one to review prior to your visit. When you arrive for your appointment, you will be asked to electronically sign that you have reviewed and understand them.

Forms to be completed:

Policies to view only

Also, please complete the below “New Patient Packet” prior to arriving for your appointment. This information is important for your physician to review with you during your initial visit and if not completed, it may delay your appointment time. You do not need to print. Once you complete and click submit, our office will securely receive your responses.

To provide you with secure electronic access to our physicians and staff, Northeast Rehab utilizes a Patient Portal. You need an access code to register. Once you receive your access code, you can click here to register. Through our patient portal, you can request appointments, update your medical history, medications, and allergies, and send a note to your provider. We encourage you to sign up for the Patient Portal before your first visit.

Allied Rehab Discharge Eval Packet