Name *

Name of the person completing this form

First Name

Last Name

Date of Birth *

For the person who will be attending therapy

MM

DD

YYYY

Are you or the person who will be attending therapy enrolled in either of the below insurance plans? *

The practice and its clinicians are out-of-network and we do not accept insurance. We are not able to provide receipts for out-of-network reimbursement for these plans. Participating in services with an out-of-network provider while enrolled in one of these plans may jeopardize your enrollment in the plan.

Medicare

Medicaid

None

Phone

(###)

###

####

How Can We Get Back To You? *

Select all that apply

E-Mail

Phone (you are authorizing us to leave a message)