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New Patient Registration Form

New Patient Registration Form

Let's Communicate uses HIPAA-compliant electronic health records. All information provided will be confidential.  Please fill out this form for each patient to be registered.  You will need your insurance cards ready to take a picture of the front and back of the card.  Once this form is completed, you will be redirected to our HIPAA Patient Consent Form to complete and sign.  Once the HIPPA Consent Form is complete, you will be redirected to our Patient Medical History Form.  All three forms need to be completed to make your first appointment and will take approximately 5-10  minutes to complete.  All forms completed will be emailed to us for processing and emailed to you for your records.  Once all forms have been processed, you will receive a call from our scheduler.  For questions, please call (678) 963-0694.  These forms are easy to complete on a mobile device or any computer.
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  • 9
    Please enter a mobile phone number
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  • 10
    If you prefer not to use your insurance, please type Private Pay in for the primary insurance. We are not accepting any new patients with Aetna, Ambetter, Humana, or United Health Care.
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    Please Upload Images of the Patients Insurance Cards
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    Please Upload Images of the Patients Insurance Cards
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    You may skip this section if you do not have a secondary insurance.
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    You may skip this section if you do not have a secondary insurance.
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    It is very important that you let us know if your child has had an evaluation somewhere else with your current insurance. If so, we have to do a transfer of services and may not be able to do another evaluation until your insurance allows a re-evaluation. All medicaid insurance allow 1 evaluation every 181 days and commercial insurance only allow 1 evaluation per year.
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    A doctors referral is required if you are using your insurance to pay for services. You can have your doctor fax the referral to (888) 547-4008 or email it to referrals@pediatrictherapy.pro
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    Amerigroup and Peachstate insurances require this in order to authorize speech therapy visits.
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    If you have a copy of the Dr Referral, IEP, hearing test results, a swallow study, psychiatric evaluations, previous evaluations at other clinics or any other information that would be helpful for the care of the patient, please fax or email it to us.

    Fax: 888-547-4008

    email: referrals@pediatrictherapy.pro

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