Public Intake ST OT ABA
Welcome to the Sunshine Center Pediatric Therapy Automated Client Intake System. Please fill out the form below and a member of our team will contact you to schedule your first appointment. if you have any questions throughout this process, feel free to contact 918-615-6492, Ext 2.
Services Needed
*
Speech Therapy
Occupational Therapy
Applied Behavioral Analysis
What is your child needing help with?
Child's Primary Care Physician
Child's First Name
*
Child's Last Name
*
Child's Date of Birth
Gender
Male
Female
Child's Address Info:
Child's Address
City
State
Zip Code
Primary Guardian Info:
Primary Parent/Guardian *
Relationship to Child *
SelectRelationship to Child
Mother
Father
Step-Parent
Grandmother
Grandfather
Sibling
Other relationship
Friend
Foster Parent
DHS Worker
Parent/Guardian Cell Phone *
Primary Insurance Info:
Primary Insurance
SelectInsuarance Plan
Patient Responsibility
/ Pt Pays After Insurance
Community Care Select
PHCS GPA
Tricare East
Resource One Administrators
PHCS-Healthcare Highways
GEHA - ASA
Anthem BH-EAP
Entrust
Allied Benefit Systems
Alliance Coal
Blue Cross Blue Shield
Cigna
First Health Network
Golden Rule Ins. Co.
Healthcare Solutions Grp
HealthChoice
Medicaid
Preferred Community Choice
UMR
United Health Care
MCD 2NDARY
Champ VA
Comm Care HMO
WEbTPA
Cigna Health & Life
United Healthcare Shared Services
United Healthcare Life Ins Comp
UMR
PHCS-Healthcare Solutions Grp
Meritain Health- Aetna
UHC West
QuikTrip
UHC Choice Plus
Self Pay
Primary Insurance Member Name
Date of Birth
Member #
Group #
Customer Service Phone #
Secondary Insurance Info:
Secondary Insurance
Select Insuarance Plan
Patient Responsibility
/ Pt Pays After Insurance
Community Care Select
PHCS GPA
Tricare East
Resource One Administrators
PHCS-Healthcare Highways
GEHA - ASA
Anthem BH-EAP
Entrust
Allied Benefit Systems
Alliance Coal
Blue Cross Blue Shield
Cigna
First Health Network
Golden Rule Ins. Co.
Healthcare Solutions Grp
HealthChoice
Medicaid
Preferred Community Choice
UMR
United Health Care
MCD 2NDARY
Champ VA
Comm Care HMO
WEbTPA
Cigna Health & Life
United Healthcare Shared Services
United Healthcare Life Ins Comp
UMR
PHCS-Healthcare Solutions Grp
Meritain Health- Aetna
UHC West
QuikTrip
UHC Choice Plus
Self Pay
Primary Insurance Member Name
Date of Birth
Member #
Group #
Customer Service Phone #
Submit