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Advantage Speech Therapy Services

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Give us a Call
404 - 784 - 1252
Send us a Message
robyn@advantagespeech.com
Therapy Hours
Mon - Thursday: 9AM - 5PM

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.

  • First Child's Info

  • Date Format: MM slash DD slash YYYY
  • If you select "Other" from the list, please enter the diagnosis description in the field:
  • 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.
  • Second Child's Info

  • Date Format: MM slash DD slash YYYY
  • If you select "Other" from the list, please enter the diagnosis description in the field:
  • 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.
  • Referral Questions

  • Parent/Caregiver Info

  • 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?
  • Alternate Location

  • Insurance

  • (Name of Parent who has the Insurance Plan)
  • Date Format: MM slash DD slash YYYY
  • Medical

  • Additional Info

  • Let us know which email to send a PDF of this form to.
  • 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
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Opening Hours
  • Monday09:00 - 05:00
  • Tuesday09:00 - 05:00
  • Wednesday09:00 - 05:00
  • Thursday09:00 - 05:00
  • FridayBy Appointment Only
  • SaturdayCLOSED
  • SundayCLOSED

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