Verification of Benefits Please note that verification of benefits is not a guarantee of payment. Clients are responsible to pay for services rendered:* Acknowledged and Agreed First Child's Name:* First Child's Gender:* Male Female First Child's DOB:* MM slash DD slash YYYY First Child's Policy ID:* First Child's Diagnosis:*If you selected "Other" from the list above, please enter the diagnosis code here: Developmental Delay(receptive/expressive language) Autism Articulation Articulation & Language Delays Second Child's Name:* Second Child's Gender:* Male Female Second Child's DOB:* MM slash DD slash YYYY Second Child's Policy ID:* Second Child's Diagnosis:*If you selected "Other" from the list above, please enter the diagnosis code here: Developmental Delay(receptive/expressive language) Autism Articulation Articulation & Language Delays Referrer Type:*How did you find us? Doctor Insurance Therapist Friend Website Referrer Name:* Parent Name:* Home Address:* Apartment #:* Apartment Complex:* City:* State:* Zip Code:* Phone:* Email:* Name of Alternate Location of Therapy:*(alternate location to consider if child is at babysitter or daycare during the day. Please write same as mother/father if address is same) Address of Alternate Location of Therapy:* Apartment #:* Apartment Complex:* City:* State:* Zip Code:* phone:* Email:* Contact Name:* Name of Subscriber:*(Name of Parent Who Has The Insurance Plan) Subscriber's DOB:* MM slash DD slash YYYY Subscriber's SSN:* Insurance Carrier :* Ex. Blue Cross, United, Aetna, etc.Insurance Customer Service Number:* Group Number:* Secondary Insurance Carrier (If applicable): Secondary Insurance Policy ID: Doctor Name:* Doctor Address: Street: City/State: Zip: Doctor Phone:* Doctor Email: Doctor Fax: Additional Comments:* CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
