Welcome to team GOAL!

Welcome to team GOAL!

We are excited to be a part of a team with you! For our first play together, please fill out this super important information. Thanks!
Para obtener una versión en español del formulario, seleccione "Español" en la parte superior derecha.
Is this a returning GOAL patient?
Has the contact info changed
Has the diagnosis, therapy, or the referring Physician changed?
Has the insurance information changed?

Patient Information (1/5)
Patient Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Guardian's Name

First NameLast Name
Relationship to the patient
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Which Goal Region are you in?
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code

Therapy and Referral Information (2/5)
Diagnosis/Condition
Who were you referred by?
Referring Physician
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Therapist
Therapy Facility
Therapy Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Insurance Information (3/5)
Primary Insurance
Insurance Type
Are you (the patient's guardian) the primary Insurance subscriber?
Insurance subscriber's Name

First NameLast Name
Subscriber DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Policy Number
Group Number
Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Upload Insurance Card

Cancelof
Is there a secondary Insurance
Secondary Insurance
Secondary Insurance Type
Secondary Policy Number
Secondary Group Number
Secondary Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Upload Secondary Insurance Card

Cancelof

Approvals & Consent (5/5)
Medical Release
Signing for Device
What is the name of the individual who will sign for your device?
Digital Contact
Insurance Appeal Option
Signature

HIPAA RELEASE: By signing above I hereby authorize the release and disclosure of my protected health information (PHI) as defined by the Health Insurance Portability and Accountability Act (HIPAA) and its regulations. The purpose of disclosure shall be for providing medical treatment and processing of any associated claims. The information shall only be disclosed to healthcare providers, health insurance companies and business associates as necessary to conduct standard business practices. This HIPAA Release authorization is valid starting the date of my signature below. I have been informed and understand that I have the right to revoke this authorization at anytime by providing written notice. However, any disclosures made prior to the revocation based on this authorization will remain valid. I understand that my failure to sign or the cancellation of this authorization does not avoid from receiving treatment, enrollment, or eligibility for or benefits I am entitled to receive, provided the information herein shall not be required in determining whether I am eligible to receive treatments or benefits or to pay for the services I receive.
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: