Prenatal History - Please describe any complications before, during, and after birth:
Approximate Age of Developmental Milestones:
Please discuss the current status of the following:
*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.
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.
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.