Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Patient InformationPatient Name *FirstMiddleLastGender *- Please select -MaleFemaleOtherDate of Birth *SSN *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePatient Phone *If registering a child, please provide the parent or guardian's phone number.LayoutPrimary InsuranceMember No.Layout (copy)Secondary InsuranceMember No.Has this patient previously been known by another name? *YesNoIf Yes, please provide the previous name:Physician/NP/PA InformationLayoutName *PhoneChronic Health ConditionsLayoutCheckboxesHigh Blood PressureCongestive Heart FailureHigh CholesterolObesityThyroid DiseaseDiabetesNeuropathyCOPDDementiaDepression/AnxietyIf other, please specifyCheckboxesObstructive Sleep ApneaLow Back PainSeizure DisorderStroke/HAChronic Kidney DiseaseBlindnessTremorsHeart AttackOtherAuthorizationI hereby authorize: 1) the release of medical information by my primary care physicians, hospitals, nursing facilitates and/or outpatient facilities to OT2GO for the purpose of obtaining authorization for services to be rendered or for the payment of insurance claims 2) authorize release of medical information between OT2GO, physicians, insurance company(s), hospitals, nursing facilities, and/or outpatient facilities that may require filing of an insurance claim or appeal a claim on my behalf. I also give authorization to my insurance company to pay OT2GO for services provided. I hereby authorize future contact for care from OT2GO, follow up, and continual treatment, regarding the services that have been provided. My plan of care allows for OT2GO to continue this contact, at any future time, while I receive services from OT2GO.Your Signature *Clear SignaturePlease sign to confirm the information provided for registration.Policy Acknowledgment *I have read and understand the OT2GO Policy.I have read and understand the HIPAA Policy.I consent to be treated by OT2GO.Please check the boxes below to confirm that you have read and understood the following policies. By checking these boxes, you acknowledge that you have reviewed and comprehended the policies outlined by OT2GO. It is essential to familiarize yourself with these policies to ensure a clear understanding of our practices and commitments to your privacy. If you have any questions or concerns, please don't hesitate to contact our office.If you are not the patient, please specify your relationshipPatient's SignatureClear SignatureThe patient must sign to confirm that they would like to be added to the UNOS Register(s) selected above.Submit
