Scoliois Intake Packet- Adult Form
New Patient Information
Patient name: *
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Patient date of birth: *
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Patient address (city, state, zip): *
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Patient phone number: *
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Patient email:
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Payment Policy
Scoliosis Physical Therapy is now a participating provider with BCBSLA, Vantage Health Plan and Medicare. Please provide your insurance information below for us to check your physical therapy benefits prior to your visit.

If you we do not participate with your insurance, we will provide an invoice you may submit to your insurance carrier to file for repayment on your own.

You can also pay out of pocket for your visit. Please call us for an anticipated cost of your visit.

Any copayments, coinsurance or out of pocket cost will be due at time of visit. Please discuss with us ahead of time if you will need a payment plan option.

Cancellations within 24 hours and/or failure to show to scheduled appointment will incur a $25 fee. For Shreveport office, you must provide at least 48 hour notice for a cancellation or rescheduling of the visit or a $25 fee will be charged. Patients coming from out of town and scheduling "intensives" will be required to provide a $100 deposit to reserve your appointment time. If appointment is cancelled $100 deposit is forfeited. If needing to reschedule appointment due to "life events" the deposit will be transferred to next appointment. Once visit is complete $100 deposit will be refunded less copayments, coinsurance, etc. when applicable.

Forms of payment: Payment may be made by check, cash, Visa, Mastercard, American Express or Discover. (make checks payable to Ashley Pittman or Scoliosis Physical Therapy) You may also use your Health Savings or Flexible Spending account for payment.

By typing your name, you consent to our payment policy: *
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Do you plan on using your insurance? *
Insurance carrier
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Member ID
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Insured name (if not self)
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Secondary insurance
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