Clinic Annual Update 2020

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Please answer the questions below regarding any changes coming in 2020. Please fill out a separate form for each child if you have multiple children receiving services.

This must be submitted by December 12, 2019

Please contact your providers with any questions:
Timber Ridge Pediatric Therapy: office@trptkids.com
Wee Speech: office@weespeech.com
ABS Behavioral Services: sarah@absbehavioralservices.com

Email *

Client Last Name *

Client First Name *

Name of person completing form *

Does your child receive speech therapy? (Wee Speech) *

Yes

Does your child receive occupational therapy (Timber Ridge Pediatric Therapy) *

Yes

Does your child receive behavioral services (ABS) *

Yes

Check the box for any service you are interested in adding in 2020

ABS Behavioral Services

Occupational Therapy/Timber Ridge Pediatric Therapy

Speech Therapy/Wee Speech, P.C

Will your insurance change as of January 2020? *

Yes

Maybe

I understand and accept that if my insurance changes and I have not provided updated insurance information the full session bill will be my financial responsibility. *

Yes, I understand

Required

Will your credit card change as of January 1, 2020? *

Yes

Maybe

Has there been a change in your preferred email address? *

Yes

Has there been a change in your residential address? if so please update below. (if not, state "no") *

Has there been a change in your phone number? if so please update below. (if not, state "no")? *

Has there been any other change that we should know about? (personal info, medical, marital status, financially responsible party) *

Yes

I understand that I am responsible for all copays/coinsurance and deductibles for 2020 and that my credit card will be charged after insurance has processed the claim. (contact your provider with any questions) *

I understand

Required

For ABS & Timber Ridge Pediatric Therapy: Beginning Jan 1, 2020 the following new policy will be enforced. Clients who arrive more than 10 minutes late to a scheduled session may be charged the prorated amount that is not insurance billable. This policy is being implemented to insure your child receives the full session minutes. This fee is not insurance billable. *

I understand

Required

Our clinic offers multiple services, all individually owned. If your child receives more than one service and you'd like communication between disciplines at the clinic please print your name below.

Updated release of information 2020: Please write the name, e-mail address, and phone number for anyone you'd like to add or delete from your current release of information. This gives your current providers permission to share information (written reports, phone conversations, meetings, e-mail correspondence).

Is there anything else you'd like us to know?

Send me a copy of my responses.

Submit

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