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Case History Form2020-06-16T13:39:14+00:00

Case History Form

  • Date Format: MM slash DD slash YYYY



  • SIBLING INFORMATION


  • BIRTH HISTORY


  • MEDICAL HISTORY

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

  • OTHER PROFESSIONALS WORKING WITH YOUR CHILD


  • MOTOR DEVELOPMENT (note age of)


  • FEEDING DEVELOPMENT (note age of)


  • SPEECH AND LANGUAGE DEVELOPMENT (note age of)


  • PSYCHOLOGICAL AND NEUROLOGICAL DEVELOPMENT


  • EDUCATIONAL DEVELOPMENT


  • INSURANCE INFORMATION

    In order to submit claims for insurance reimbursement, we will need the following information:

  • Date Format: MM slash DD slash YYYY

  • FINAL INFORMATION

    It may be helpful to keep a 2 day log of foods your child eats and bring this information to your first appointment.

  • Terms of Agreement I hereby authorize Miracle Family Speech Therapy (MFST) to submit a claim to my insurance carrier for all covered services rendered by the therapist and authorize and direct my insurance carrier or its intermediaries to issue payment checks directly to the therapist rendering the covered service. I will be responsible for those charges deemed not covered by said insurance carrier so long as such insurance has not been deemed such services to be medically inappropriate or unnecessary. I also understand that if my insurance company is not a contracted carrier, I am responsible for the full fee charged by my therapist regardless of what my insurance pays. I authorize MFST to furnish complete information to my insurance carrier and its intermediaries regarding the services rendered. I permit a copy of this authorization to be used in the place of the original. I consent to assign all payments for these services to this practice. I understand that I am responsible for all co-payments, amounts applied to deductibles and any coinsurance amounts, as required by my contract with my insurance plan and state regulation. I further understand that my contract with my insurance entity may or may not cover some services. It is my responsibility to obtain information from my health plan about service coverage. If I seek care outside of the contact, I am aware that I may be responsible for all charges that are incurred. If for any reason my insurance plan does not pay for my approved charges in full, I agree to be fully responsible for the amount. I also agree should collections be necessary for payment of my account, to be fully responsible for any collection fees and associated costs.

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