Hallmark - Speech Therapy
Please complete this form, in order to schedule an appointment. We will check your insurance benefits and provide a good faith (cost) estimate for services.
We are currently accepting waitlist clients only. Please confirm you would like to be on the waitlist.
*
Yes
Client Name
*
First Name
Last Name
Preferred Name
Parent/ Caregiver Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Client Date of Birth
*
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Month
-
Day
Year
Date
Gender - as identified by Insurance
*
Please Select
Female
Male
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Self- Identified Gender
Insurance or Self Pay
*
Please Select
Insurance
Self Pay
Insurance Subscriber/Guarantor Name
*
First Name
Last Name
Insurance Subscriber Date of Birth
*
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Month
-
Day
Year
Date
Insurance Payer Name (etc. Carefirst)
*
Enter 0 if Self Pay
Insurance ID # (enter 0 if self pay)
*
Upload a Copy of your insurance card (if available)
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Upload a Copy of your insurance referral (if available)
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Notes - Please enter any additional information that you would like to provide.
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