Registration Form

Child's First Name

Child's Last Name

Child's Date of Birth

Child's Gender

Female

Male

Parent/Guardian First Name

Parent/Guardian Last Name

Cell Phone #

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Primary Diagnosis and Service(s) requested:

Dr. Name or Name of the Office

Dr. Office Phone Number

Dr. Office Fax Number

Parent Email Address

Primary Insurance Company

Member or Policy ID #

Group #

Secondary Insurance Company

Member or Policy #

Group #

*** Please attach a photo of the front and back of all insurance cards.

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Therapist's name if known

Also, if applicable, Please upload:

1. Any recent evaluation your child has received within the past year.

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2. A current copy of your child’s IEP if applicable.

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Is your child is in the Babies Can’t Wait Program?

Yes

For speech therapy authorizations, Peachstate and Amerigroup require a current hearing evaluation. The newborn screening can be used for children ages 0-3.

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Address where service is to take place:

Home

Other

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