Registration Form
Child's Full Name:
First Name
Last Name
Date of birth
Gender of child:
1. Parent/Guardian Name:
Phone
*
Home Address
State
City
Postal code
2. Parent/Guardian Name (if applicable):
Cell Phone #
Home Address 2
Primary Diagnosis and Service(s) requested:
Dr. Name or Name of the Office
Dr. Office Phone Number
Dr. Office Fax Number
Parent Email Address
*
Primary Insurance Company:
Member or Policy ID #:
Group #:
Secondary Insurance Company:
Member or Policy No.
Group No.
*** Please attach a photo of the front and the back of all insurance cards.
Drop files here
Therapist's name if known
Also, if applicable, Please upload:
1. Any recent evaluation your child has received within the past year.
2. A current copy of your child’s IEP if applicable.
Drop files here
Is your child is in the Babies Can’t Wait Program?
Is your child is in the Babies Can’t Wait Program?
Yes
No
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For speech therapy authorizations, Peachstate and Amerigroup require a current hearing evaluation. The newborn screening can be used for children ages 0-3.
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Address where service is to take place:
Address where service is to take place:
Home
Other
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