THERAPY INTAKE

Please enter all information to the best of your ability. If you have any questions please feel free to Contact Us directly!

    Patient Information:

    Patient Name:
    Date of Birth:
    Diagnosis:

    Address:
    Major Crossroads:
    Email:

    Primary Phone:
    Secondary Phone:
    Work Phone:

    Name of Parent/Guardian:
    Name of School/Teacher:
    School Phone:

    Pediatrician:
    Address:
    Phone:

    Neurologist:
    Address:
    Phone:

    Siblings:

    Sibling Name: Age:
    Sibling Name: Age:
    Sibling Name: Age:

    Developmental History:

    Prenatal History - Please describe any complications before, during, and after birth:

    Approximate Age of Developmental Milestones:

    Roll:
    Sit Alone:
    Crawl:
    Walk:
    First Word:

    Please discuss the current status of the following:

    Mobility:
    Feeding:
    Speech:

    Medical History:

    Previous Hospitilizations/Surgeries - Please list type, date, and doctor:

    Current Medications:
    Drug/Food Allergies:

    Patient Info:

    Patient Name:
    Date of Birth:
    Age:
    Gender:

    Address:
    City:
    State:
    Zip Code:

    Home Phone:
    Email:
    Recieve email updates? Yes Please!

    Father:
    Mobile/Work Phone
    Diagnosis:

    Mother:
    Mobile/Work Phone
    Pediatrician:

    Insurance Information

    *Please note that if you have private insurance seperate from DDD/AHCCCS your private insurance must be listed as primary and then your DDD/AHCCCS can be listed as secondary. It is required by DDD that we bill primary insurance prior to billing DDD.
    Primary Insurance Plan:
    Employer:

    Policy Holder:
    Birthdate:

    Group #:
    Id or Policy#:

    Effective date:
    Termination Date:
    Phone:

    Send Claims To Address:
    City:
    State:
    Zip:

    Secondary Insurance Plan (if applicable):
    Employer:

    Policy Holder:
    Birthdate:

    Group #:
    Id or Policy#:

    Effective date:
    Termination Date:
    Phone:

    Send Claims To Address:
    City:
    State:
    Zip:

    Medical Information Release

    I hereby authorize the release of medical records, or copies of the records, to be transferred to Lexington Therapy Services. 1337 S. Gilbert Rd, Ste 105, Mesa, Arizona 85204 with a fax number of (480) 530-0890. I also authorize Lexington Therapy Services. to release information, records, or copies of records, pertaining to the diagnosis, as well as, treatments and examinations, which have been provided, to my insurance providers and my other health care agencies.

    Financial Policy

    I understand and agree that I am ultimately responsible and liable for payment of all charges assessed for professional services provided by Lexington Therapy Services, and will pay any sum due upon demand. I understand that insurance claim forms will be submitted to my insurance company as a matter of convenience. I understand and agree that if it becomes necessary to retain an attorney and/or collection agency for the collection of any outstanding charges, whether or not a lawsuit is filed on my account, I will be responsible for any attorney and/or collection fees and court costs in addition to the outstanding balance. Patients authorized for therapy by the Arizona Department of Economic Security, Division of Developmental Disabilities, are not responsible for payment charges.

    Assignment of Benefits

    I request that payment of authorized insurance benefits be made on my behalf to Lexington Therapy Services. I promise to the best of my knowledge all of the information on this application is true and correct.

    CONTACT ANY LOCATION

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