Referral for Outpatient Therapy and Admission Form

Client Information

Insurance Information

(Please give your insurance card to the office manager.)

In Case Of Emergency

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize [Name of Practice] or insurance company to release any information required to process my claims.

Patient/Guardian Signature