Patient Intake and Financial Form | EBS Children's Therapy of Georgia

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
Father's Name
First Last
Date of Birth
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
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*

Insurance Information