Caregiver's Name:

Patient's Name:

Patient's Date of Birth:

Email:

Phone Number:

I am inquiring about the following therapy services:
Speech TherapyOccupational TherapyPhysical TherapyTeletherapyGroup Therapy

How did you hear about us?
DoctorPsychologistSchoolCommunity EventCommunity FlyerFamily/Friend/Word of MouthInternet SearchInstagramFacebookBTS TherapistPrevious ClientCurrent Client

Reason for seeking services:

Insurance Information

Benefit Therapy Services is in network and contracted with Blue Cross Blue Shield, United Healthcare, UMR, Cigna, NC Health Choice, Medicaid, Medicaid Managed Care Plans, Medicare, Medcost, Aetna, and Tricare. Private pay is also accepted. We are always open to becoming an in-network provider for other private insurance companies so please ask if your insurance provider is not listed above.
Benefit Therapy Services is happy to contact your insurance provider and file our services on your behalf. However, we strongly recommend contacting your insurance company directly to verify your benefits. Clients, or their legal guardian, are responsible for co-pays, co-insurance, and/or deductibles as well as any costs or fees not covered by their insurance plans.

Type of Insurance
Please select all insurances that apply:
NC Medicaid Managed Care Plan (Medicaid Direct, Amerihealth Caritas, Blue Cross Healthy Blue, Carolina Complete, United Healthcare Community Plan, and Wellcare)TricareCommercial Insurance (Aetna, Armada Care, Blue Cross Blue Shield, Cigna, MediShare, Medcost, UMR, United Healthcare)Self-Pay (will not submit to any insurance)