Coach House Physical Therapy

Serving the community for over 22 years!

17453 Jefferson Davis Hwy. · Dumfries, VA 22026 | Ph: 703-221-3913 · Fax: 703-221-3203 · Billing: 703-221-3931

Insurance Information

Please fill out any and/or all insurance information that we will need for billing purposes. Please fill out one form at a time and click submit. If you have to add more than one insurance, please fill out next form, then click submit.

Primary Insurance Information

Secondary Insurance Information

Insurance Phone Number:
Policy Holder's
Policy Holder's SSN:
Employer Name if Through Employer:


Policy Identification Number:
Policy Holder's DOB:
Employer Name if Through Employer:

Workers' Compensation Insurance Information

Patient Name: