INSURANCE

INTAKE FORM

To begin the authorization process for services through insurance, please fill out the Intake Form below. Please contact our Admissions Team at admissions@rcsconsultingne.com or 508.650.5990 ext. 2008 with any further questions.

INSURANCE INFORMATION:

Patient's Name

Patient's DOB

Address

City

State

ZIP

Country

Insurance Provider

Insurance ID #

Group #

Insurance Phone # (Provider Services or Behavioral Health)

Parent/Guardian Name

Home Phone

Cell Phone

Primary Diagnosis

Secondary Diagnosis

Subscriber Name

Subscriber DOB

Employer

State Insurance is issued

Yes No

SECONDARY INSURANCE (IF APPLICABLE)

Do you have Secondary Insurance?

Yes No

Secondary Insurance Subscriber Name

Secondary Insurance Subscriber DOB

Secondary Insurance # and Group #

SERVICE NEEDS INFORMATION

Current School Hours

AVAILABILITY FOR SERVICES:

Availability on Mondays

Availability on Tuesdays

Availability on Wednesdays

Availability on Thursdays

Availability on Fridays

How many hours are desired per week?

Other additional information

INSURANCE

INTAKE FORM

INSURANCE INFORMATION:

SERVICE NEEDS INFORMATION

RCS Behavioral & Educational Consulting

RCS Early Childhood Office

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