Insurance Options

At Kids Therapy Corner we provide the service of submitting invoices directly to your insurance company if you prefer. We suggest prior to the initial evaluation you call your insurance company and become familiar with your current coverage and policy. Some insurance companies require a Dr referral stating medical necessity for services and/or pre-authorization prior to receiving therapy. If you discover this is the case for your policy, please let us know and we are more than willing to help you gather this information.

Cardholder's Name

First NameLast Name

Cardholder's Birthdate

MonthDayYear

Primary Insurance Provider

Insurance Provider Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Group Number*

ID Number*

Insurance Provider Number*

Area CodePhone Number

Secondary Insurance

I hearby authorize Kids Therapy Corner, LLC to release records to the insurance company or other payers as requested in order to authorize therapy and to faciliate claims payment. In addition, failure to provide all informaiton regarding insurance coverage (primary and/or secondary) will result in delays which will affect treatment.

Name

First NameLast Name

Signature