Insurance Policy Information

How will you be paying for services?*

InsuranceCash, Credit or Check

Please enter ALL policies your child is covered under. If you do not enter all policies, you may be responsible for the full payment of claims.

If you're able, please upload a picture of the front and back of your insurance card(s)

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Primary Insurance Company Name:*

$ Amount of Insurance Deductible, if not applicable write "N/A":*

Deductible met?*

YesNoN/AOther

Amount of deductible remaining if known:

Insurance Co-Insurance percentage, if not applicable write "N/A":*

Insurance Co-pay, if not applicable write "N/A":*

# of visits allowed, if not applicable write "N/A":*

Is authorization required for Occupational Therapy?*

YesNoOther

Insurance Policy #*

Insurance Group #

Insurance Customer Service/Provider Phone # (on the back of the card):*

Area CodePhone Number

Who is the primary subscriber on the insurance policy?*

First NameLast Name

Primary subscribers Date of Birth:*

MonthDayYear

Primary Insured Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary subscriber's relationship to patient:*

Parent/GuardianSelfOther

Is there a Secondary Insurance?*

YesNo

If YES, please fill out Secondary insurance info below.

Secondary Insurance Company

Secondary Insurance Policy #

Secondary Insurance Group #

Who is the secondary subscriber on the insurance policy?

First NameLast Name

Secondary subscribers Date of Birth:

MonthDayYear

Secondary subscriber's relationship to the patient:

Parent/GuardianSelfOther

Financial Policy:
You are responsible for payment for services you receive at ‘Ohana Occupational Therapy. It is your responsibility to know your deductible, co-insurance and co-pay. All treatments must be justified and medically necessary in order for us to treat and bill your insurance. For medically necessary service your deductible, co-insurance and/or co-pay are due at the time of service. If your insurance requires pre-authorization, we will work with your insurance company to obtain the necessary authorization for services. For all non-covered services payment must be made at the time of service. It is the policy of Ohana Occupational Therapy that insurance copayment/coinsurance is due on or before the date of the visit. We do offer discounted cash packages to patients. If you wish to opt out of using your insurance for services, due to a high deductible/co pay, etc., we will not bill your insurance. If we participate with your insurance plan, you must opt out completely (with no insurance involvement) in order to pay out of pocket.

I understand that it is my responsibility to advise ‘Ohana of all insurance in which my child has coverage. It is also my responsibility to advise ‘Ohana immediately of any changes in insurance or lapses in coverage, even if my child has Apple Health(WA State Insurance). Omissions may result in charges for the visit. Patient responsibility for services rendered is due on or before the date of the visit.

Parent/Guardian Signature*

Insurance Policy Information

Payment Information