Preparing for your first visit
Please complete all forms and submit online. Services will NOT start if all forms are not completed in full. Please choose the category that fits the best. Please call us at 316-440-3316 if you have any questions regarding form completion.
A. Forms for COMMERCIAL and MEDICAID insurance policies/IN-NETWORK: *Required
1. Client Information and Payment/Insurance Information*
3. Pediatric Health Questionnaire*
B. UNITED HEALTH CARE Commercial: *Required for UHC Commercial policyholders only.
Must complete forms 1-5e above*
AND
6. UHC Out of Network Contract
C. Forms for any child in FOSTER CARE: *Required for children in foster care only.
Foster PARENT/CAREGIVER to Complete:
Must complete forms 1-5 listed above*
AND
Release of Information- Parent/Caregiver*
AND
Release of information- General
Foster Care AGENCY REPRESENTATIVE/CASE MANAGER to Complete:
Must complete forms 1-5e above*
AND
Foster Care Agency Information
D. Bi-annual Pediatric Health Questionnaire and Change of Status Questionnaire
Bi-annual Patient Health Questionnaire - For existing clients only
Forms will be hyperlinked
FORMS
Insurance
Insurance coverages are a contract between you and your insurance policy. We accept insurance as a courtesy to you. We will attempt to collect costs from your insurance company as outlined in your plan. However, verifications are not a guarantee that services will be covered even if stated so by a representative of your insurance company. It is RECOMMENDED that you familiarize yourself with your policy and contact your insurance company on your own. We have found that there are times they give us different information and/or provide the insured party with additional information. Additionally, if an insurance company denies and you have proof you called, they are more likely to overturn your denial on YOUR behalf. When we call and subsequently there is a denial, there is not leniency. You can use the following questions as guides:
1. Are OT services covered?
2. Are there any exclusions? (i.e.: developmental delay or other diagnoses, age exclusions)
3. Are there any exclusions in my policy that are specific to OT?
Always document the time/date and get a confirmation number for your conversation.
Methods of Payment
In Network Insurance Plans:
Aetna, Coventry, PHC, Cigna, HPK, BCBS, Optum, Meritain,
Tricare, WWPA and affiliated policies, First Health, and many more.
In Network Medicaid:
United Kancare and Aetna Better Health of Kansas
Out of Network Insurance Plans:
United Commercial Policies and Sunflower but we will work with you so that your services go towards your deductibles when possible.
Private Pay
Cash, Checks, and Credit Cards Accepted
Questions about cost of services can be directed to Julie Frazier:
(ph) 316-263-0776, (Fax) 316-263-0817, or email juliefrazier@medisourcehcs.com