Get Office Registration Form - Playworks

Filling out the Office Registration Form - PlayWorks online is a straightforward process designed to gather essential information for therapy services. This guide will walk you through each section of the form to ensure you complete it accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the Office Registration Form - PlayWorks and open it in your preferred editor.
2. Enter the date in the designated field to indicate when you are completing the form.
3. Fill in the last name, first name, and middle initial of the client as requested. Ensure accurate spelling.
4. Provide the client’s Social Security number in the appropriate section for identification.
5. Complete the street address, city, state, and zip code fields for the client’s residence.
6. Input the client’s date of birth to assist with age-related services.
7. Select the appropriate sex designation by marking either ‘F’ for female or ‘M’ for male.
8. Include home, cell, and work phone numbers as applicable for contact purposes.
9. Enter a valid email address to facilitate communication.
10. Indicate which phone number is the best for reaching the client.
11. In the responsible party section, fill out the names and dates of birth for the mother and father as required, along with their Social Security numbers.
12. If applicable, provide information for any additional caregiver, including their name and phone number.
13. Complete the insurance section by naming the referring physician, detailing any diagnoses, and indicating if the client has received any therapies within the last 6 months.
14. List the primary insurance provider and attach copies of all relevant insurance cards as instructed.
15. Complete the place of employment entry for the responsible party and attach any required prescription documents.
16. If the client is enrolled in waiver programs, please include relevant agency information as well as the service coordinator's name and contact number.
17. Fill out the emergency contact's name, their relationship to the client, and their phone number.
18. Read and sign the consent for occupational, physical, and/or speech therapy, ensuring to date the signature.
19. Complete the assignment and release section, sign, and date it as well.
20. Finally, review the entire form for accuracy; once completed, save the changes, and choose options to download, print, or share the form as necessary.

Start completing your Office Registration Form - PlayWorks online today!