Commercial Insurance Information

INSURANCE POLICY HOLDER Date of Birth

Address of INSURANCE POLICY HOLDER

Same as Patient Address

INSURANCE POLICY HOLDER Employer

Insurance Company Name

Member ID

N/A

Group Number

N/A

Plan Number

N/A

Coverage Effective Date

Visits Shared with Other Services (OT, ST)?

YesNoPatient/Caregiver will contact Insurance

Pre-Authorization Required for PT?

YesNoPatient/Caregiver will contact Insurance

Max PT Visits Per Year

While CPTA is happy to assist our pateints by billing their insurance, it is the patient/caregiver's responsibility to understand their specfic insurance plan benefits.

Continue to Medicaid Information

Medicaid Information

Medicaid Member ID

N/A

Medicaid Plan

UHC Community PlanHealthy Blue

Medicaid Coverage Effective Date

Address of Medicaid Policyholder

Same as Patient Address

Special instructions

 📎 Insurance Card Required Please include a copy of insurance card(s) — front & back — with this form.

Continue to Signature

Important Notice: It is the responsibility of the parent/caregiver to report any changes in this information to CPTA by phone (913) 345-1997 or email CPTA@pt4Rkids.com.

Your Signature

Please fill in/select each field.

Signature Date