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Adult Patient Intake
Please fill out all information below.
For which location are you requesting an evaluation?
*
Marlton
Swedesboro
Haddonfield
Telehealth
Contact Information
Date of Form Submission:
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-
Month
-
Day
Year
Date
Patient Name
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First Name
Last Name
Patient Date of Birth
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-
Month
-
Day
Year
Date
Patient Gender
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Male
Female
Prefer not to Answer
Is there a language other than English spoken in the home?
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No
Yes
If yes, what other language are you exposed to at home?
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What is your dominant language?
*
Do you consider yourself to be bilingual/multilingual?
*
No
Yes
Are translation services necessary for the evaluation?
*
No
Yes
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Cell Phone Number
*
Please enter a valid phone number.
Patient Email
*
example@example.com
How did you hear about MJ KIDZ?
I heard from:
*
Please Select
Word of Mouth
Previous/Current Patient
Google
Facebook
Instagram
Physician
Other Medical Professional
Insurance
Preschool
School
Marketing Material
Marketing Event
Other:
We want to thank our referrals! Please be as specific as possible or put N/A:
*
Insurance Information
Would you like to use your insurance, private pay, or our MVP Program for Medicaid Patients?
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Insurance
Private Pay
MVP Program for Medicaid Patients
Please note that by choosing private pay I cannot and will not be submitting claims to my insurance company directly. Prior to scheduling an initial evaluation, I understand that I will need to receive and sign a Good Faith Estimate for an estimated cost of services.
*
Please note that by choosing MVP Program for Medicaid Patients I cannot and will not be submitting claims to my insurance company directly. Prior to scheduling an initial evaluation, I understand that I will need to receive and sign the MVP form for estimated cost of services.
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Primary Insurance (Please Select)
*
Please Select
Aetna
Amerigroup
AmeriHealth Administrators
Amerihealth NJ
Anthem
Blue Cross Blue Shield (Various States)
Cigna
Corsource
Federal Blue Cross Blue Shield
GEHA
Horizon Blue Cross Blue Shield of NJ
Horizon NJ Health
Humana
Independence Blue Cross
Independence Personal Choice
Independence Administrators
Keystone
Medicare
Meritain
Tricare
*
ID Number
Group Number
Phone Number
*
Please enter a valid phone number.
Effective Date
*
-
Month
-
Day
Year
Date
Subscribers Name
*
First Name
Last Name
Subscriber's Date of Birth
*
-
Month
-
Day
Year
Date
Please upload FRONT of insurance card.
*
Browse Files
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Choose a file
Cancel
of
Please upload BACK of insurance card.
*
Browse Files
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of
Please upload drivers license of primary subscriber.
*
Browse Files
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Choose a file
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of
Do you have secondary insurance?
*
Yes
No
Secondary Insurance
*
Please Select
Aetna
Amerigroup
AmeriHealth Administrators
Amerihealth NJ
Anthem
Blue Cross Blue Shield (Various States)
Cigna
Corsource
Federal Blue Cross Blue Shield
GEHA
Horizon Blue Cross Blue Shield of NJ
Horizon NJ Health
Humana
Independence Blue Cross
Independence Personal Choice
Independence Administrators
Keystone
Meritain
Medicare
Tricare
United Health Care Community Plan
*
ID Number
Group Number
Phone Number
*
Please enter a valid phone number.
Effective Date
*
-
Month
-
Day
Year
Date
Subscribers Name
*
First Name
Last Name
Subscriber's Date of Birth
*
-
Month
-
Day
Year
Please upload FRONT of insurance card.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload BACK of insurance card.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload drivers license of primary subscriber.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Primary Care Physician Information
Primary Care Physician Name
*
Primary Care Physician Practice
*
Primary Care Physician Phone Number
*
Please enter a valid phone number.
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Primary Concerns
What is your primary reason for seeking Speech-Language Pathology services? Why do you feel that you need cognitive-communicative, speech and language, swallowing, voice or augmentative and alternative communication therapy? Please be as specific as possible.
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Does you have any medical diagnoses or pertinent medical history to your concerns? e.g. Autism, Vocal Nodules, TBI etc.
*
Describe any evaluations and/or therapy you have undergone for communication, swallowing, behavioral, emotional, or other difficulties. If none, mark "N/A."
*
Do you have any concerns regarding your feeding and swallowing skills?
Yes
No
Concerns regarding picky eating
Concerns regarding choking/gagging
Other
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