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Pediatric Rehabilitation and Wellness Intake
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* Indicates required question
Patient name
*
Your answer
Patient Date of Birth
*
MM
/
DD
/
YYYY
Patient legal sex
*
Female
Male
Gender
Your answer
Patient Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip code
*
Your answer
Responsible Party 1 name
*
Your answer
Responsible Party 2 name
Your answer
Hospital of birth (if your child is under 4 years old) (in certain cases insurance requires that we request newborn hearing screening from the state of Georgia. The request form requires this information)
Your answer
Mother's name at birth of child (if your child is under 4 years old) (in certain cases insurance requires that we request newborn hearing screening from the state of Georgia. The request form requires this information)
Your answer
Mobile Number
*
Your answer
May we contact you by text message at this number?
*
Yes
No
Alternate phone number
Your answer
May we contact you by text message at this number?
*
Yes
No
Email address
*
Your answer
May we communicate by email?
*
Yes
No
By typing my name below I am indicating that I understand text messaging and email communication may not be secure or encrypted and I accIt the risk indicated herein that protected health information may be accessible by unauthorized third parties.
*
Your answer
Referring Physician
*
Your answer
Primary Insurance
*
BCBS/Anthem
Humana
Medicaid
Caresource
Peachstate
Wellcare
Amerigroup
Cigna
United Healthcare
UMR
Aetna
Tricare Select
Tricare Prime
Tricare Standard
Healthgram
Ambetter
None/Self Pay
Other:
Primary Insurance Policy number
*
Your answer
Primary Insurance Group number (if none write none)
*
Your answer
Secondary Insurance
*
BCBS/Anthem
Humana
Medicaid
Caresource
Peachstate
Wellcare
Amerigroup
Cigna
United Healthcare
UMR
Aetna
Tricare Select
Tricare Prime
Tricare Standard
Healthgram
Ambetter
None/Self Pay
Other:
Secondary Insurance Policy number (if none write none)
*
Your answer
Secondary Insurance Group number (if none write none)
*
Your answer
Does the patient have an IEP (special education plan for school), IFSP, (Babies Can't Wait) or ISP (COMP/NOW)?
Yes
No
Clear selection
If you child is in Babies Can't Wait, what is the name of the service coordinator?
*
Your answer
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