• Speech Therapy Intake Form

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  • Medical History

  • Please list any physicians or specialist that provide care for your child

  • Social/Emotional History

  • Feeding history: At what age was your child introduced to:

  • Therapy Information

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  • Please List therapies your child is receiving:

  • Educational Information

  • If you checked YES and your child is covered by Georgia Medicaid please provide a copy of your child's IEP as required by Georgia Medicaid

  • Insurance Information: Please understand you are financially responsible for what your insurance doesn't cover.

  • Please sign the box below indicating that you will pay for therapy if your insurance does not cover services

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  • Consent to Bill and Treat

  • CONSENT FOR TREATMENT

    I am aware that my child has  has a diagnosis requiring speech therapy, voluntarily consent to such care for the aforementioned child by CommuniCare Therapy Services, Inc. as may be beneficial in the professional judgment of this child’s therapist. 

    I am aware that the practice of speech therapy is not an exact science and I acknowledge that no guarantee has been made to me as to the effect of speech therapy treatment for my child.
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  • RELEASE OF TREATMENT

    I hereby authorize CommuniCare Therapy Services, Inc. to release to my Insur ance Companies only such
    therapeutic and financial information as may be necessary to determine benefits entitled and to process payment claims for therapy services that will be provided. I hereby authorize CommuniCare Therapy Service Inc. to release to attending physicians and therapist therapeutic and financial information as may be necessary to coordinate my Child’s therapy plan of care.
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  • CONSENT FOR PAYMENTI authorize CommuniCare Therapy Services, Inc. to bill my insurance company for direct reimbursement of therapy services rendered to my child. Benefit payment will be assigned directly to CommuniCare Therapy Services, Inc. c/o Lisa Lester. I understand the Medicaid r ate will be accepted and billed if Georgia Medicaid covers my child. If I am not covered by Georgia Medicaid, I will be charged a maximum of $250 for Speech Therapy Evaluation and $150 for any Speech Therapy Treatment not covered by my insurance company.I understand that I am responsible for payment for any service rendered to my child not covered up to the rates mentioned above.
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  • Reload
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