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Home
Services
Adult Services
Swallowing Disorders or Dysphagia
Post-Stroke Rehabilitation
Cognitive-Communication Disorders
Accent Reduction/Modification
Voice Disorders
Pediatric Services
Speech And Language Therapy
Occupational Therapy
Feeding Therapy
Reading/Dyslexia, Auditory Processing, And Listening Skills
Social Skills Groups
Early Intervention
About Us
Our Team
Our Treatment Approach
Forms
Blog
Contact
Patient Intake and Financial Form
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Forms
/ Patient Intake and Financial Form
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Patient's Name
*
First
Last
Date of birth
*
Date Format: MM slash DD slash YYYY
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone
*
Cell Phone
*
Email
*
Mother's Name
First
Last
Date of Birth
MM
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DD
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YYYY
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2021
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Father's Name
First
Last
Date of Birth
MM
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11
12
DD
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31
YYYY
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
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2006
2005
2004
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Pediatrician/Doctor
First
Last
Clinic Name
Phone
Fax
Child's Diagnosis (if known) and Year
Reason for Referral
Insurance Information
Primary Insurance
Phone
Mailing Address for claims
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Subscriber's Name
First
Last
Subscriber's Date of Birth
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
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1958
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1955
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1953
1952
1951
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1949
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1921
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Policy ID #
Group #
Employer/Group Name
Katy Beckitt Waiver
Yes
No
Medicaid
Yes
No
Peachstate
Medicaid #
My signature indicates that, to the best of my knowledge, all information provided above is accurate and current. I understand if additional service time is requested on my part above what is recommended, I agree to pay the current private pay rate for any additional service time. I understand that if my insurance or Medicaid information changes at any time, it is my responsibility to notify Chandler Speech and Language Services, LLC of the noted changes. Failure to do so will result in my responsibility for payment of services if insurance/Medicaid denies services due to lack of authorization and/or verification of benefits.
Name of Person Completing This Form:
*
First
Last
Today's Date
*
Date Format: MM slash DD slash YYYY
Relationship to Patient:
*
Signature
*
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