Insurance Information & Coverage Form

INSURANCE INFORMATION AND COVERAGE FORM

Responsible Party Information (Either Client or Parent/Guardian)

First Name(Required)
Last Name(Required)

Patient Information

Patient Name(Required)
If you have medical insurance and would like to receive the maximum benefits available to you from our insurance company, it is important that you contact your insurance company prior to your first visit. We are available to answer any insurance questions you may have, however, St Croix Therapy can only assist you and cannot guarantee payment from your insurance company.

Please contact your insurance company for the following information:

Does my policy cover habilitative therapy service for the following disciplines? (check all that apply)(Required)
Do I need prior authorization or an insurance referral for Occupational Therapy?(Required)
Do I need prior authorization or an insurance referral for Physical Therapy?(Required)
Do I need prior authorization or an insurance referral for Speech Therapy?(Required)
Does my policy cover sensory integration?(Required)
For Speech Therapy does my policy cover stammering or stuttering?(Required)
Are there visit limitations for therapy services?(Required)
Do I have a deductible?(Required)
Do I have a co-insurance for each visit?(Required)
Do you have an office copayment for each visit?(Required)