New Patient Forms and Process - Synaptic Pediatric Therapies

Patient Full Name

Date of Birth

Sex

Caregiver's Name

Caregiver Phone Number

Caregiver Email

Address

City

State

Zip Code

Primary Care Physician’s Name

How did you hear about this practice?

Clinic Location

Comments and Messages

Insurance Information

Upload Insurance

Please upload a copy/photo of the insurance card or bring it with you to the evaluation appointment

Primary Insurance

Member ID

Group Number

Phone Number

Secondary Insurance

Member ID

Group Number

Phone Number

Payment Policy:

Co-pays and Co-insurances are due at the time of service, or full payment is due for self-pay patients unless prior arrangements have been made with our billing department. We accept cash or credit cards (Visa, MasterCard and Discover). On a limited basis checks may be accepted and there is a service charge on any returned check; payment in full will be required within 10 days of notice.

Insurance:

Our office will kindly bill your insurance company. We participate with a number of medical insurance plans that we will contact to verify eligibility and benefits. Please realize that you have the ultimate responsibility of verifying the coverage with your insurance. You acknowledge that we may be an out of network provider with your insurance. You are also aware that in some circumstances your insurer will send payment directly to you. You agree to endorse the insurance check and forward funds to the appropriate entity above within 30 days of receipt. You will be responsible for any balance not paid or denied by your insurance carrier. Patients who do not supply accurate insurance information will be considered self-pay. You must inform our office of any changes in your insurance, as you are the policyholder and it is your responsibility.

Caregiver Signature

(Printed name will count as Signature)

Relationship to Patient

Date