Insurance Information & Coverage Form INSURANCE INFORMATION AND COVERAGE FORM Today's Date(Required) Month Day Year Responsible Party Information (Either Client or Parent/Guardian)First Name(Required) First Last Name(Required) Last Phone(Required)Email(Required) Patient InformationPatient Name(Required) First Patient Name(Required) Last 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:Insurance Company(Required) Does my policy cover habilitative therapy service for the following disciplines? (check all that apply)(Required) Occupational Therapy Physical Therapy Speech Therapy Do I need prior authorization or an insurance referral for Occupational Therapy?(Required) Yes No Do I need prior authorization or an insurance referral for Physical Therapy?(Required) Yes No Do I need prior authorization or an insurance referral for Speech Therapy?(Required) Yes No Does my policy cover sensory integration?(Required) Yes No For Speech Therapy does my policy cover stammering or stuttering?(Required) Yes No Are there visit limitations for therapy services?(Required) Yes No Number of visits allowedDo I have a deductible?(Required) Yes No How much of the deductible has been met?Do I have a co-insurance for each visit?(Required) Yes No Percentage of co-insurance? Do you have an office copayment for each visit?(Required) Yes No Copayment amount
