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?

For speech therapy authorizations, Peachstate and Amerigroup require a current hearing evaluation. The newborn screening can be used for children ages 0-3.

Drop files here

Address where service is to take place:

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