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*
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*
Is there a second child?*
- Yes
- No
Second Child's Info
Name*
First Last
DOB*
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*
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*
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*
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Enter Email Confirm Email
Comments
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robyn@advantagespeech.com

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Wednesday09:00 - 05:00
Thursday09:00 - 05:00
FridayBy Appointment Only
SaturdayCLOSED
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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

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