Prairie State Rehab: forms before your visit

Your equipment supplier filled in some of these details. Please fix anything that's wrong.

Patient

Full name Date of birth Address

Phone Email

Primary insurance Member ID Secondary insurance Member ID

We'll ask this office for your records. If you don't know their fax number, leave it blank and we'll find it.

Doctor's name Practice name

Phone Fax, if you know it

Other doctors to request records from (name and fax, up to three)

Entire record

Entire record except the items I check below

Mental health records

Communicable diseases (including HIV and AIDS)

Alcohol / drug abuse treatment

Other

Other (please explain)

Consent to record the visit.

Text messages may also go to a caregiver:

Caregiver name Relationship

Caregiver mobile

Notice of Privacy Practices

Patient Bill of Rights

Take a photo of each side, or choose one you already have.

Front of card

Back of card

I am the patient

I am signing for the patient

Sign with your finger or mouse

By signing, I agree to everything on this form.