Forms

Financial Agreement Case History Patient Information Privacy Form (HIPPA) Acknowledgement of Receipt of Services          Vea en español Financial Agreement Case History Privacy Form (HIPPA) Acknowledgement of Receipt of Services          Listening Skills Forms Listening Skills Inventory LSI Instructions

All forms in Adobe PDF Format If you don't have the free Adobe reader, download it here.

Insurance

We are currently in-network with these insurance plans:

• BCBS of Georgia, PPO & POS plans
• Private Health Care Systems, PPO plans
• Aetna US Healthcare, PPO, POS, & HMO
• Group Resources
• Meritan Health
• Beachstreet
• Great West
• Tricare South
• Guardian
• Coventry
• All Medicaid CMO’s and Peachcare for Kids

To Get Started

Your child's file must be complete with all items prior to starting therapy.

___   Prescription from your child's primary care physician with ICD-9 code for a diagnosis and frequency of visits.

___   Current Evaluation if already completed from your previous Speech, Occupational or Physical Therapist, less than 12 months old.

___   Case History Form

___   Financial Agreement

___   Privacy Policy

___   Insurance Information: please copy the front and back of your primary and secondary insurance.

___   Medicaid Information: a copy of Medicaid card and a copy of the current months eligibility form*

___   Preauthorization: Please check with your insurance company to see if they require preauthorization**

___   Current IFSP: if ages 0 to 3 years and participating in the Georgia Babies Can't Wait Program

*   Medicaid Information: Traditional Medicaid, Deeming Waiver, Peachcare for Kids, or CMO.
** Preauthorization: If preauthorization is required, you will need to go through this process prior to beginning therapy.