First Point of Contact form:
Please use this form every time an inquiry for services comes in. Please follow the flow of the form and ask about the potential client's insurance LAST.
Parent's name:
*
First Name
Last Name
Age of your child:
*
Does your child have a diagnosis?
*
Yes
No
Name of child's diagnosing doctor (if applicable):
*
What kind of insurance do you have?
*
Aetna
APD
AvMed
Baycare
Blue Cross/Blue Shield
Cigna
CMS
Humana
Life Sync
Medicaid
MH Net
New Directions
TriCare
United Healthcare
Not covered/Private Pay
Other
Insurance information:
Does your child receive other therapy services? (Please list below)
Additional notes:
What facility are they interested in?
*
Brandon
Carrollwood
Tampa
Wesley Chapel
Not clear/Unknown
Action Item:
*
Schedule 'meet & greet'
N/A
Parent's e-mail address:
*
example@example.com
Parent's phone number:
Format: (000) 000-0000.
Employee e-mail address (to send copy of information):
*
example@example.com
Submit
Should be Empty: