FULP THERAPY SERVICES, INC. - Communication Specialists for Children
Insurance Information
Patient Name__________________________Date of Birth______________
Home Address__________________________________________________
Home Phone______________Social Security #_______________________
Mother's Employer________________________Work Phone_____________
Father's Employer________________________Work Phone_____________
Mother's cell____________________Father's cell_____________________
Primary Insurance Company____________________________________
Group #___________________Subscriber ID_________________________
Name of Policy Holder_________________Date of Birth________________
Social Security #_____________________Driver's License #____________
Phone Number for Benefits/Authorization____________________________
Secondary Insurance Company_________________________________
Group#__________________Subscriber ID___________________________
Name of Policy Holder________________Date of Birth_________________
Social Security #___________________Driver's License #______________
Phone Number for Benefits/Authorization____________________________
Referring Physician______________________________________________
Phone #_________________
Assignment of Insurance Benefits to Fulp Therapy Services, Inc.:  I authorize direct payment of medical benefits to Fulp Therapy Services, Inc.  The benefits referred to herein would be payable to me if I did not make assignment and include major medical insurance.  I understand that I am personally responsible to Fulp Therapy Services, Inc. for charges not covered or paid by this assignment.
Fulp Therapy Services, Inc. is authorized to release any medical information required in the administering of applications for financial coverage for services required.  They may also send the results of my child's evaluation and recommendations to the referring physician for coordination and continuity of care.  I have carefully completed this form and to the best of my knowledge, it does not contain any false, incomplete or misleading information.
Parent/Guardian signature               Date