Let's Get Started!

*Before any speech evaluation begins, the following information is
required. Evaluations will NOT be preformed without:

An ORIGINAL prescription/referral for services from your child’s pediatrician for ‘Speech Evaluation & Treatment’ is required before ANY speech evaluation is

rendered, which  should include:

 1. Child’s Name & D.O.B.

 2. Date of the Prescription must be WITHIN 6 mos of date of evaluation.

 3. Diagnosis codes for Speech Evaluation and Treatment (Dr. will write on this prescription).

 4. Insurance card

 5. Audiogram (If Amerigroup is your insurance).

Click To Download Registration Form

Registration Form for Speech/Language Therapy

Client (Child) Information:












 


 



MaleFemale



Third Party Payment Sources (Please complete whether or not pay source covers your treatment as Babies Can’t Wait)



YesNo
(If yes, complete insurance information below)


---------- INSURANCE INFORMATION ----------








 


 


 








ASSIGNMENT OF INSURANCE BENEFITS AND RELEASE OF INFORMATION

Policy Holder check one and sign below:
Consent to treatment and authorization to release information and assignment of benefits:

I hereby authorize the staff of Divine Speech to perform such evaluative and therapeutic procedures, as they may deem necessary or advisable from time to time. I further authorize Divine Speech to release any appropriate evaluative and/or therapeutic treatment information to the Center’s therapeutic and consultant team, and/or to third-party payers (Medicaid, or private insurance companies when needed for reimbursement purpose).

I agree to be personally responsible for any charges to my account.



Please upload your signature



---------- SECONDARY INSURANCE ----------








 


 


 



ASSIGNMENT OF INSURANCE BENEFITS AND RELEASE OF INFORMATION

Policy Holder check one and sign below:
Consent to treatment and authorization to release information and assignment of benefits:

I hereby authorize the staff of Divine Speech to perform such evaluative and therapeutic procedures, as they may deem necessary or advisable from time to time. I further authorize Divine Speech to release any appropriate evaluative and/or therapeutic treatment information to the Center’s therapeutic and consultant team, and/or to third-party payers (Medicaid, or private insurance companies when needed for reimbursement purpose). I agree to be personally responsible for any charges to my account.

I elect not to assign benefits to Divine Speech at this time. I understand that I may request to do so at a later date. I further understand that I am directly responsible to Divine Speech for the full charge of all services rendered.

Please check that you have agree and read all the information.



Please upload your signature


Parental Information







 


 




 


 





 


 



Consent to treatment and authorization to release information and assignment of benefits:

I hereby authorize the staff of Divine Speech to perform such evaluative and therapeutic procedures, as they may deem necessary or advisable from time to time. I further authorize Divine Speech to release any appropriate evaluative and/or therapeutic treatment information to the Center’s therapeutic and consultant team, and/or to third-party payers (Medicaid, or private insurance companies when needed for reimbursement purpose).

I agree to be personally responsible for any charges to my account



Please upload your signature