OT Intake Form | Connections EIAS

Initial Intake for Occupational Therapy Services

Thank you for your interest in outpatient Occupational Therapy services at Connections Early Intervention & Supports. Please provide the following information and someone will be in touch soon to discuss next steps!

Name of person completing form:

Date:

Relationship to child:

Phone:

Email:

CHILD'S INFORMATION

Full Legal Name:

Nickname

Gender:

Date of Birth

Age:

Street Address:

City:

State:

Zip code:

Please describe the challenges your child is facing and what you are hoping can be addressed through Occupational Therapy:

Have you tried to address these challenges before now? If so, briefly describe:

PAYMENT & INSURANCE

INSURANCE: Connections EIAS is currently in network with Highmark Blue Cross, Capital Blue and UPMC Health Plan for in-clinic Occupational Therapy services. Please note that at this time, we are not in network with PA Medicaid.

For all other clients, we are able to provide a detailed receipt for clients to submit for out of network reimbursement, if eligible. Please check with your insurance company regarding benefits and reimbursement processes.

PRIVATE PAY: We offer private pay options for clients not utilizing insurance benefits. Current rates can be discussed during intake.

PLEASE CHOOSE FROM THE FOLLOWING OPTIONS:

I have Highmark Blue Cross, Capital Blue or UPMC Health Plan and will be using insurance for services.

I will be utilizing private pay options.

I am not sure if you accept my insurance. Can you help?

PRESCRIPTION

I understand that I will be responsible for reaching out to my child's Pediatrician to obtain a prescription for services.

INSURANCE PLAN

Policy Holder's Full Name:

Date of Birth

Insurance Provider:

Member ID & Group # (if applicable)

Insurance Card (Front)

Upload File

Upload supported file (Max 15MB)

Insurance Card (Back)

Upload File

Upload supported file (Max 15MB)

EVALUATION AVAILABILITY

In-person evaluations are an essential part of the intake process and can be scheduled on select weekdays here in our clinic either in the AM (9 AM - 12 PM) or PM (12 - 4 PM).

Please list all days and times that you would be available to bring your child for an evaluation: