New Patient Intake Form 2024
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Please read the information carefully, complete it, and return to us so we can start the insurance benefits check process.  
Please call your pediatrician’s office and ask for a prescription for OT/ST to evaluate/treat services. Insurance companies require the prescription for reimbursement purposes.

Cowtown Pediatrix is in-network with Blue Cross Blue Shield and Cigna/ASH (American Specialty Health).

Cowtown Pediatrix is out of network with all other commercial insurance companies including Tricare/Military.

You will need to pay your co-pay or in-full for each appointment in accordance with the terms of your insurance company policy.

Your child’s evaluation will last approximately 1-2 hours (OT), 1 hour (Speech).  We schedule evaluations during the school hours.  However, if your child is recommended for therapy, we will do our best to accommodate your schedule with after school appointments, if needed. Once we receive your insurance information, we can schedule your child’s evaluation.  
Please answer the following questions.
Today's date: *
Patient name and DOB: *
FULL patient address (Address, city, state, and zip code): *
Cell phone number AND email: *
Please fill out the following insurance information.
Insurance company name: *
Member ID # *
Group # *
Member's name: *
Member's date of birth: *
MM
/
DD
/
YYYY
If Military- Rank: *
Are you on active duty? *
Reason for OT/ST evaluation / primary concerns: *
Referred by: *
Diagnosis: *
Please enter Pediatrician's name: *
A copy of your responses will be emailed to the address you provided.
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