Clinic Annual Update 2020
Please answer the questions below regarding any changes coming in 2020. Please fill out a separate form for each child if you have multiple children receiving services.

This must be submitted by December 12, 2019

Please contact your providers with any questions:
Timber Ridge Pediatric Therapy: office@trptkids.com
Wee Speech: office@weespeech.com
ABS Behavioral Services: sarah@absbehavioralservices.com
Email address *
Client Last Name *
Your answer
Client First Name *
Your answer
Name of person completing form *
Your answer
Does your child receive speech therapy? (Wee Speech) *
Does your child receive occupational therapy (Timber Ridge Pediatric Therapy) *
Does your child receive behavioral services (ABS) *
Check the box for any service you are interested in adding in 2020
Will your insurance change as of January 2020? *
I understand and accept that if my insurance changes and I have not provided updated insurance information the full session bill will be my financial responsibility. *
Required
Will your credit card change as of January 1, 2020? *
Has there been a change in your preferred email address? *
Has there been a change in your residential address? if so please update below. (if not, state "no") *
Your answer
Has there been a change in your phone number? if so please update below. (if not, state "no")? *
Your answer
Has there been any other change that we should know about? (personal info, medical, marital status, financially responsible party) *
I understand that I am responsible for all copays/coinsurance and deductibles for 2020 and that my credit card will be charged after insurance has processed the claim. (contact your provider with any questions) *
Required
For ABS & Timber Ridge Pediatric Therapy: Beginning Jan 1, 2020 the following new policy will be enforced. Clients who arrive more than 10 minutes late to a scheduled session may be charged the prorated amount that is not insurance billable. This policy is being implemented to insure your child receives the full session minutes. This fee is not insurance billable. *
Required
Our clinic offers multiple services, all individually owned. If your child receives more than one service and you'd like communication between disciplines at the clinic please print your name below.
Your answer
Updated release of information 2020: Please write the name, e-mail address, and phone number for anyone you'd like to add or delete from your current release of information. This gives your current providers permission to share information (written reports, phone conversations, meetings, e-mail correspondence).
Your answer
Is there anything else you'd like us to know?
Your answer
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