Island Wide Speech Intake Form

Client Information

First Name *

Middle Initial/Name

Last Name *

Birth Date *

Gender * (as listed on ins. card)
MaleFemale

Preferred Pronouns

Address 1 *

Address 2

City *

State *

Zip *

Home Phone

Cell Phone

Allow Text Messages
YesNo

Email *

Spouse/Caregiver #1

Name

Relationship

Occupation

Birth date

Spouse/Caregiver #2

Name

Relationship

Occupation

Birth date

Release Forms and Procedures

Authorized Signature Release Form
Please read the Island Wide Speech Authorized Signature Release Form

I have read and agreed to the Island Wide Speech Authorized Signature Release Form.
I agree

Attendance Policies and Sick Procedures
Please read the Attendance Policies and Sick Procedures at Island Wide Speech

I have read and agreed to the Attendance Policies and Sick Procedures at Island Wide Speech.
I agree

Teletherapy
Please read the Island Wide Speech Teletherapy Consent Form

I have read and agreed to the Teletherapy Consent Form for Island Wide Speech.
I agree

Notice of Privacy Practices
Please read the Island Wide Speech Notice of Privacy Practices

I have read and agreed to the HIPAA Notice of Privacy Practices for Island Wide Speech.
I agree

Insurance Information

I understand it is my choice to attend sessions at Island Wide Speech either through insurance or private pay.

Insurance Policy Questions

Please read the Insurance Policy Questions to ask your Insurance questions

If attending via insurance, I agree to call my provider and ask the above questions in regards to my policy’s coverage of speech therapy.
I agree

Insurance Reimbursement Agreement

I understand that if my insurance denies reimbursement for claims submitted by Island Wide Speech, I will be responsible for all outstanding claims/payments.
I agree

Primary Insurance

Please select your primary insurance:

Member ID:

Group ID:

Subscriber's First Name

Subscriber's Last Name

Subscriber's Birth Date

Subscriber's Gender (as listed on ins. card)
MaleFemale

Upload Insurance Card
Please send us a copy of the front and back of your insurance card.

Do you have a secondary insurance?
YesNo

Secondary Insurance

Please select your secondary insurance:

Secondary Member ID:

Secondary Group ID:

Secondary Subscriber's First Name

Secondary Subscriber's Last Name

Secondary Subscriber's Birth Date

Secondary Subscriber's Gender (as listed on ins. card)
MaleFemale

Upload Secondary Insurance Card
Please send us a copy of the front and back of your secondary insurance card.

Upload your Prescription.

Please sign

Name of person completing form *

Relationship to client *

Please sign below: *

Island Wide Speech · fara@islandwidespeech.com · (516) 415-2751 · Plainview, NY

Island Wide Speech Intake Form

Client Information

Medical History

Release Forms and Procedures

Insurance Information