The patient's care is our primary concern -
Contact is maintained with the patient's physician for optimum treatment
- Worker’s Compensation Insurance
- Auto Med Pay
- Az State Fee for Service AHCCCS
- Blue Cross/Blue Shield-ALL PRODUCT LINE
- Health Net with prior Authorization
- Indian Health Services (IHS/CHS)
- Medicare Part B
- Personal Injuries with LIEN
- Schaller Anderson (STATE & U of A)
- Self Pay
- Tricare/Champva- PRIME and STANDARD
- University Family Care (AHCCCS GROUP)
- University Physician Healthcare
Most PPO Plans-CALL FOR VERIFICATON
R & R PHYSIAL THERAPY APPRECIATES YOUR REFERRALS |
NAME: _____________________________ APPT DATE & TIME: __________________
PHONE #: ________________________ DOB: _____________________________
PROBLEM: _____________________________________________________________
_______________________________________________________________________
REFERED BY: ____________________________________________________________
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PT TYPE: INS. - MEDICARE - MED PAY - LIEN - WKR'S COMP - CASH
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INSURANCE CO: ___________________________ PHONE #: _____________________
ID/CLAIM # _____________________ GROUP # _______________________________
PRIMARY INSURED: _______________ _____________________ DOB _______________
RELATIONSHIP TO PT: _______________________ EMPLOYER: __________________
DATE: ___________________________
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Please fax this form to (520) 325-2007