Intake Form

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Intake Form

If you are scheduled with Wheels on the Bus' services, please fill out the intake form below.

You can alternatively download the PDF and email to [email protected]

Thank you!

Intake Form (PDF download)

Client Name*

Address*

City*

State*

Zip Code*

Phone Number*

Gender*

DOB*

Patient/Guardian Name(s)*

Client Doctor (Full Name)*

Doctor's Full Address*

Doctor's Fax Number*

Diagnosis*

Insured Information (Name)*

Parent/Caregiver info if client is listed under insurance

Address*

Please include address, city, state, and zip code

Phone Number*

Gender*

DOB*

Employer*

Employer Phone*

Insurance Company Information*

Who is your insurance carrier?

Effective Date*

Plan (HMO/PPO/Other)*

Billing Address*

Please include address, city, state, and zip code

Insurance Company Phone*

ID #*

Group #*

Authorized Signature*

I hereby authorize the release of any medical or other information necessary to file a claim with my insurance company. I also request payment of government and and/or insurance benefits to Wheels on the Bus Pediatric Therapy. I understand that I am responsible for any and all bills incurred and that any third party coverage or insurance is for the purpose of assisting me with my responsibility. If I receive a payment from the insurance company, I understand that this payment along with the Explanation of Benefits (EOB) needs to be submitted to Wheels on the Bus Pediatric Therapy within five (5) business days of receipt of this information or I will be billed directly for all services rendered.

Medical Release*

I hereby certify that I am a parent or lega guardian of the client listed, and give Wheels on the Bus Pediatric Therapy permission to provide services to the client. I authorize Wheels on the Bus Pediatric Therapy to request, obtain, and provide medical information to and from the appropriate doctors, medical facilities, insurance companies, payment services, and /ro any other entity that will assist in rendering therapy services.

Cancellation Policy*

If I need to cancel an appointment, I understand that I will cancel/reschedule an appointment by giving a 24-hour notice when possible. Wheels on the Bus Pediatric Therapy reserves the right to discontinue services at any time. I also understand that the therapist will call if they are going to be more than 15 minutes late for a scheduled appointment. I ti is my responsibility to ensure that Wheels on the Bus Pediatric Therapy and the therapist have my most up-to-date information to include telephone and address. I also understand that the therapist will keep all appointments and from time to time may need to cancel/reschedule an appointment within less than 24 hours due to illness/emergency. If i feel that the therapists cancels frequently or is not providing quality services, I will contact Wheels on the Bus Pediatric Therapy immediately to resolve these issues.

I Understand and Agree to the Cancellation Policy

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Wheels on the Bus Pediatric Therapy, Inc.

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