Keri Skipper, MCD CCC-SLP
Phone: 864-406-6769
Email: [email protected]
Web: pathwayspediatrictherapysc.com
Patient Information, Therapy Authorization, and Financial Responsibilities
Name: _________________________________Date of Birth:_______________Age:________________
Address:______________________________________________________________________________
Referring Physician:_______________________________Phone #:_______________________________
Patient’s Social Security #:________________________________________________________________
Phone:(primary)____________________(secondary)___________________(work)__________________
Caregivers Name (and relationship):________________________________________________________
Email address:_________________________________________________________________________
Primary Insurance Coverage Information:
Payor:________________________________Plan Policy #:___________________Group #:___________
Claims address:____________________________________________Phone:_______________________
Policy Holder Information:
Full Name:__________________________Relationship to patient:__________________DOB:________
Employer:____________________________________________________________________________
Address and Phone # (if different from patient):______________________________________________
Secondary Insurance Coverage Information:
Payor:________________________________Plan Policy #:___________________Group #:___________
Claims address:____________________________________________Phone:_______________________
Policy Holder Information:
Full Name:__________________________Relationship to patient:__________________DOB:________
Employer:_____________________________________________Gender:_________________________
Address and Phone # (if different from patient):______________________________________________