REFERRAL INFORMATION
Date of referral
For

PT Eval
OT Eval
SLP Eval
Type of Payment

SSI
Cash
Private Insurance
Other:

Medicaid: ID#
Medipass
Staywell
Straightcaid
PHP
Problem please explain:
Primary MD

 

PATIENT INFORMATION
Childs Name
DOB
Age
SSN
Parent/Guardian
Address
Home Phone
Work Phone
Cell Phone
Email

 

INSURANCE INFORMATION
Primary Insurance Co.
Name
Address
Phone
Policy holder
DOB
Policy #
Customer Service Phone #
Group #
   
Secondary Insurance Co.
Name
Address
Phone
Policy holder
DOB
Policy #
Group #
   
 

 

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To make a referral, please call us at 863.294.1429.
Our Children's Rehab Center : 150 Avenue B, SE : Winter Haven, FL 33880 : info@ourchildrensrehab.org