Patient Information, Therapy Authorization, and Release Form

Patient Information, Therapy Authorization, and Release Form
Patient Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Age
Patient’s Social Security Number
Patient Address

Referring Physician
Physician Phone #
Format: (000) 000-0000.
Caregiver's Name (and relationship)
Caregiver Phone (home)
Format: (000) 000-0000.
Caregiver Phone (work)
Caregiver Phone (cell)
Caregiver Phone (other)
Caregiver's Email address
example@example.com

Primary Insurance Coverage Information
Payor
Plan Policy #
Group #
Claims Address
Phone
Format: (000) 000-0000.
Policy Holder Information:
Full Name
Relationship to patient
DOB
Employer
Gender
Address (if different than patient)
Phone # (if different than Patient)
Format: (000) 000-0000.

Secondary Insurance Coverage Information
Payor
Plan Policy #
Group #
Claims address
Phone
Format: (000) 000-0000.

Policy Holder Information:
Full Name
Relationship to patient
DOB
Employer
Gender
Address (if different than Patient)
Phone # (if different than Patient)
Format: (000) 000-0000.
Patient Financial Responsibility (please initial each):
I understand that I have been referred for therapy services and care with Spoken Word Children's Therapy. I understand that I have the right to ask and have any questions answered prior to receiving any treatment, including any risks or alternatives to the treatment plan that has been prescribed by my physician and/or recommended by my therapist. By signing this agreement, I consent to have Spoken Word Children's Therapy provide treatment and care as prescribed by my physician and/or recommended by my therapist.
Initial Here
I hereby authorize Spoken Word Children's Therapy to furnish my insurance company(s) any information that may be required in order to determine benefits and process claims. I authorize payment of medical benefits to Spoken Word Children's Therapy for services rendered to me. I certify by my initials that I have read the above and agree to this policy.
Any services rendered are charged to the patient and due at the time of service. As a courtesy Spoken Word Children's Therapy will file your claim with your insurance carrier, however the patient or responsible party is ultimately responsible for the charges not covered by your insurance. Any copayments or deductible amounts not satisfied with your carrier are due at the time of service. It is the patient’s responsibility to understand their insurance coverage.
It is the patient’s responsibility to understand their insurance coverage. Statements from Spoken Word Children's Therapy are due upon receipt. If a discrepancy exist with your balance due, please contact Spoken Word Children's Therapy otherwise your payment is expected upon receipt. Unpaid balances can ultimately result in accelerated collection practices.
I acknowledge that I am financially responsible to Spoken Word Children's Therapy for any balance not covered under my plan from my insurance carrier. Patient Name
Patient Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Witness
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Spoken Word Children's Therapy, Inc.

P.O. BOX 2467 Mount Pleasant, SC 29465 | (850) 341-0418

Should be Empty:

Patient Information, Therapy Authorization, and Release Form

Primary Insurance Coverage Information

Policy Holder Information:

Secondary Insurance Coverage Information

Policy Holder Information: