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  • Client Intake Form

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  • Insurance Company and Policy#: Primary Care Physician:

  • BIRTH HISTORY

  • DEVELOPMENTAL HISTORY

    At what age did your child: 
  • MEDICAL HISTORY

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  • Permission Form

  • give permission for an evaluation to be conducted with my child to determine if therapy is needed. I also give my permission for treatment, if deemed necessary by test results and the child’s primary care physician.

  • Clear
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  • MEDICAID RELEASE AND ASSIGNMENT

  • I request that authorized Medicaid Payments be made to Let's Talk Speech Pathology Services, LLC, for any services furnished by them to my child.

  • Clear
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  • INSURANCE RELEASE AND ASSIGNMENT

  • and assigned directly to Let’s Talk Speech Pathology Services, LLC, all insurance benefits, if any, otherwise payable to me for services, rendered. I understand that I am financially responsible for aU charges whether or not paid by insurance. I hereby authorize Let’s Talk Speech Pathology Services, LLC and/or Central Arkansas Therapy to release all information necessary to secure payments of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic.

  • Clear
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  • PRIVACY POLICY

  • have received a copy of the privacy policy. The privacy policy can be obtained from our website at www.letstalkar.com/parent-resources.

  • Clear
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  • Should be Empty: