Love Therapy Service, El Paso TX

New Patient Form

Complete this New Patient Form prior to your first visit with us. Complete the form in its entirety and click submit when completed.

Last Name*

First Name*

Sex

Date of Birth*

Address*

State*

City*

Zip Code*

Phone Number*

Physician

Insurance Information

Insurance Company Name

Policy #

Address

City

State

Zip Code

Medicaid

Yes

Medicaid Number

I authorize Love Therapy Service to bill my insurance company directly for the covered portion of charges and I authorize payment of benefits directly to Love Therapy Service. I authorize Love Therapy Service to release medical or other information necessary to process this claim. I understand that I am ultimately responsible for my therapy charges and I agree to pay my deductible co-insurance or co-payment and any charges not reimbursed by my insurance carrier. I understand that some insurance companies require medical or administrative pre-authorization for treatment or have reimbursement limits on therapy treatments. I understand I am responsible for knowing and meeting the requirements of my insurance plan and/or Medicaid.

I agree that my typed/electronic signature is the legal equivalent of my manual/handwritten signature on this document.

Signature

Date*

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