New Patient Evaluation

Full Name *

Date of Birth *

Sex *

• Male
• Female

Preferred contact method:

First

Last

Preferred contact method: *

First

Last

Address *

Address Line 1

City

State / Province / Region *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Social Security Number *

Parent's Name *

Parent Employer *

Primary Care Physician’s Name *

How did you hear about this practice? *How did you hear about this practice? *DoctorFriend,Family MemberGoogle,Yelp,FacebookOther(Insurance Website, etc...)

Clinic Location *Clinic Location *ArlingtonDeSotoGarlandIrvingMesquiteNorth Richland HillsRichardsonRoyse CityWylie

Insurance Information

Please upload a copy/photo of the insurance card or bring it with you to the evaluation appointment!

Upload InsuranceFile Upload

Click or drag files to this area to upload. You can upload up to 5 files.

Primary Insurance *

Member ID *

Group Number

Phone Number

Secondary Insurance *

Member ID *

Group Number

Phone Number

Payment Policy:

Co-pays and Co-insurances are due at the time of service, or full payment is due for self-pay patients unless prior arrangements have been made with our billing department. We accept cash or credit cards (Visa, MasterCard and Discover). On a limited basis checks may be accepted and there is a service charge on any returned check; payment in full will be required within 10 days of notice.

Insurance:

Our office will kindly bill your insurance company. We participate with a number of medical insurance plans that we will contact to verify eligibility and benefits. Please realize that you have the ultimate responsibility of verifying the coverage with your insurance. You acknowledge that we may be an out of network provider with your insurance. You are also aware that in some circumstances your insurer will send payment directly to you. You agree to endorse the insurance check and forward funds to the appropriate entity above within 30 days of receipt. You will be responsible for any balance not paid or denied by your insurance carrier. Patients who do not supply accurate insurance information will be considered self-pay. You must inform our office of any changes in your insurance, as you are the policyholder and it is your responsibility.

Checked *

• The above information on all pages of this document is thorough and accurate to the best of my knowledge. For any changes to the above information, I will notify the office.

Checked *

• I consent to evaluation and treatment by any provider at Synaptic Pediatric Therapies. I hereby authorize release of medical information that is necessary for my further treatment.

Checked *

• I authorize release of information, including treatment and protected health information to my insurance company that is needed to process payment for services. I authorize my insurance carrier to pay benefits for services rendered, directly to Synaptic Pediatric Therapies LLC, or any of its affiliates. I have read and agree to the terms of the above information.

Patient or Parent / Guardian Signature (Printed name will count as Signature) *

Relationship to Patient *

Date *

Submit