Initial Inquiry Form

Completing this form will indicate to our staff that you would like to be contacted about initiating therapy services for you or your child. Our Intake Coordinators will contact you within 48 hours to gather more information, answer your initial questions, and potentially schedule you or your child for services. Completing this form will allow our intake coordinators to come fully prepared to meet your needs during their first phone call with you!

Caregiver's Name:

Patient's Name:

Patient's Date of Birth:

Email:

Phone Number:

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

How did you hear about us?

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)