Client Intake Form

  • Client Intake Form

    www.hollandpediatric.com

  • Client Information

  •  - -

  • Primary Contact Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Physician Information

  • Format: (000) 000-0000.

  • Payment Options

  • If we are in network with your insurance company, we will process those claims and bill you for the unpaid balance. You are responsible for contacting your insurance company for coverage amounts.

  • We must have a copy (front and back) of your insurance card prior to start of services.

    Deductible: The amount you must pay before your insurance company will begin paying for your child’s therapy. Co-Pay: The amount you must pay at each visit after you have met your deductible.

  • Our office will process your child’s claims directly to Medicaid. It is your responsibility to obtain a prescription and clinic notes indicating a need for therapy from your doctor for services requested. If your child receives special services, including speech therapy in the public schools, you must provide our office with a copy of the current Individual Education Plan (IEP). You must keep us informed of any changes in your child’s Medicaid coverage or change of physician.

  • Our office will process claims to your insurance company first. The insurance company will send out an Explanation of Benefits (EOB). Our office must have a copy of the EOB in order to process your claim. When you receive an EOB, you are responsible for sending it to our office by email (diane@hollandpediatric.com), fax (405) 708-5353, or in person. Your child’s service will be placed on hold until the EOB is received. If your insurance does not process a claim within 30 days of our submitting the claim, your child’s therapy will be placed on hold.

  • If we are “out of network” with your insurance company, or you do not have private insurance, you are considered a self-pay client. You are responsible for all charges.

  • Acknowledgement & Signature

  • I, the undersigned, assign directly to Holland Pediatric Therapy all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am responsible for all charges whether or not paid by insurance. I hereby authorize Holland Pediatric Therapy to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

    By signing below, you state that you understand the payment policy that pertains to you and that you are responsible for payment as outlined above.

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