Get Life Span Occupational Therapy Confidential Intake Data

Filling out the Life Span Occupational Therapy Confidential Intake Data online is a crucial step in beginning your therapy journey. This comprehensive guide will provide you with clear, step-by-step instructions on how to accurately complete each section of the form.

Follow the steps to successfully fill out your intake data online.

1. Click the ‘Get Form’ button to access the intake form and view it in the online editor.
2. Enter your full name in the designated fields, including first name, middle initial, and last name.
3. Input your date of birth in the specified format to ensure proper identification.
4. Select your sex by checking the appropriate box for either female or male.
5. Fill in your employer's information along with your home address, including street, apartment, city, state, and zip code.
6. Provide your contact numbers: home, cell, and work, to enable effective communication.
7. Enter your email address for any essential correspondence regarding your appointments and therapy.
8. List an alternate contact person, including their name, phone number, and relationship to you as the primary contact.
9. Identify your primary care doctor by providing their name and phone number.
10. If you have a diagnosis, please provide that information in the appropriate section when known.
11. Document details of your primary insurance company, including submitting a copy of your insurance card.
12. Fill in the subscriber's name and date of birth related to your primary insurance.
13. If applicable, provide information for a secondary insurance company, again including a copy of the insurance card.
14. If you are a military beneficiary, please provide the subscriber's social security number.
15. Indicate if you are enrolled in Medicaid or DSHS by checking the 'Yes' or 'No' box.
16. Read the assignment of insurance benefits statement and sign to authorize payments to Life Span Occupational Therapy.
17. Date your signature to complete the form.
18. Review the Patient Rights section, then initial in the box provided to acknowledge understanding.
19. Complete the release of information section by providing the necessary details about caregivers and professionals involved in your care.
20. Sign and date the release of information section, ensuring it is valid for the duration of your therapy.
21. Finalize your form by saving the changes you made, then download, print, or share the completed form as needed.

Start filling out your Life Span Occupational Therapy Confidential Intake Data online today!