Verification of Benefits Form

Verification of Benefits v2

Your Child's Safety is Our Top Priority

In order to ensure the safety of your child during his/her in-home therapy session, it's imperative that an adult be present in your household at all times. While it's not mandatory that a parent/caregiver join the actual session, it can be beneficial.
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 Info
Name*
First Last
DOB*
MM slash DD slash YYYY
Gender*
- Male
- Female
Diagnosis*
If you select "Other" from the list, please enter the diagnosis description in the field:
- Developmental Delay(receptive/expressive language)
- Autism
- Articulation
- Articulation & Language Delays
Policy ID*
Insurance and License
You may upload digital copies of the front and back of your insurance card and license here. Allowed files: PDF, Word Docs, JPG, & PNG.
Drop files here or

Accepted file types: doc, docx, jpg, jpeg, pdf, png, Max. file size: 100 MB.
Is there a second child?*
- Yes
- No
Second Child's Info
Name*
First Last
DOB*
MM slash DD slash YYYY
Gender*
- Male
- Female
Diagnosis*
If you select "Other" from the list, please enter the diagnosis description in the field:
- Developmental Delay(receptive/expressive language)
- Autism
- Articulation
- Articulation & Language Delays
Policy ID*
Insurance and License
You may upload digital copies of the front and back of your insurance card and license here. Allowed files: PDF, Word Docs, JPG, & PNG.
Drop files here or

Accepted file types: doc, docx, jpg, jpeg, pdf, png, Max. file size: 100 MB.
Referral Questions
How did you learn about Advantage Speech Therapy Services?*
- Doctor
- Insurance
- Therapist
- Friend
- Website
Who can we thank for their recommendation?
Parent/Caregiver Info
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Apartment #
Name of Apartment Complex or Sub-division
Access/Gate Code
Phone*
Email*
Will therapy need to be conducted outside the home?*
I travel to your child at the parent/guardian home. Is there an alternate location outside the home to visit? Eg, daycare, babysitters, church, preschool program?
- Yes
- No
Alternate Location
Name of Alternate Location of Therapy*
Contact Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Insurance
Name of Subscriber*
(Name of Parent who has the Insurance Plan)
First Last
Subscriber's DOB*
MM slash DD slash YYYY
Subscriber's SSN*
Insurance Carrier*
Insurance Customer Service Number
Group Number*
Is there a secondary insurance carrier?
- Yes
- No
Secondary Insurance Carrier
Secondary Insurance Policy ID
Medical
Doctor Name*
Address
Street Address Address Line 2 City State ZIP Code
Phone*
Fax
Email
Additional Info
Additional Comments*
CAPTCHA
Get a PDF copy of this form emailed to you.
Let us know which email to send a PDF of this form to.
Enter Email Confirm Email
Comments
This field is for validation purposes and should be left unchanged.

Save and Continue Later

Give us a Call

(404) 784-1252

Send us a Message

robyn@advantagespeech.com

Resources

ASTS Forms
Common Questions
FAQs
Contact Us

Facebook

Opening Hours

Monday09:00 - 05:00
Tuesday09:00 - 05:00
Wednesday09:00 - 05:00
Thursday09:00 - 05:00
FridayBy Appointment Only
SaturdayCLOSED
SundayCLOSED

Insert/edit link

Enter the destination URL

URL

Link Text

Open link in a new tab

Or link to existing content

Search

No search term specified. Showing recent items. Search or use up and down arrow keys to select an item.

Verification of Benefits Form

Verification of Benefits v2

First Child's Info

Second Child's Info

Referral Questions

Parent/Caregiver Info

Alternate Location

Insurance

Medical

Additional Info

Give us a Call

Send us a Message