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English (US)
Insurance Verification of Benefits
This information is needed so benefits for therapy can be verified prior to the start of treatment. For questions or concerns regarding billing or insurance benefits, contact our off-site billing department at 202-424-2718.
Patient status
*
New Patient
Existing Patient - Adding new therapy type / discipline
Existing Patient – New Plan Information
Office Location
*
DC
VA
Urgent/Priority
Waiting for SOB to schedule
Eval Date (if none scheduled, write TBD)
*
Admin note
Service(s)
*
OT Full Eval
OT Short Eval
OT Infant/Toddler Eval
OT Feeding Eval
OT SIPT Eval
PT Full Eval
PT Infant-Toddler Eval
PT Orthotic Eval
PT Short Eval
Speech Eval
Speech Feeding Eval
No Eval/Start OT
No Eval/Start PT
No Eval/Start Speech
Child's name
*
First Name
Last Name
Child's date of birth
*
-
Month
-
Day
Year
Date
Main concern/diagnosis
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your name (to discuss benefits)
*
First Name
Last Name
Your relationship to the child
*
Best number to reach you
*
-
Area Code
Phone Number
Phone type
*
mobile
home
work
Email
*
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Primary Insurance
Primary insurance company name
*
Subscriber name
*
First Name
Last Name
Subscriber date of birth
*
-
Month
-
Day
Year
Date
Insurance ID number
*
Group number
*
Claims mailing address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Claims contact telephone number
*
-
Area Code
Phone Number
Does your child have secondary insurance?
*
yes
no
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Secondary Insurance Company
Secondary insurance company name
Subscriber name
First Name
Last Name
Subscriber date of birth
-
Month
-
Day
Year
Date
Insurance ID number
Group number
Claims mailing address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Claims contact telephone number
-
Area Code
Phone Number
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