Please fax or scan/email completed forms to:
Due to insurance plans varying, families should contact their specific insurance company to verify benefits. When inquiring, please determine if Janet Schultz-Mroz from The Whole Child Associates is within your network plan and what that plan includes.
Families are encouraged to contact The Whole Child Associates Billing Company directly:
Jennie Parker at QTB Billing
Send Jennie a copy of the front and back of your insurance card
Policy holder’s name
Child’s full name
Your Child’s birthdate
Medical diagnosis code that was assigned by the doctor
If your child has recent medical reports from medical specialists and/or recent therapy reports, please provide this information to aid with the evaluation process.
If your child has had a recent occupational and/or physical therapy evaluation, please provide the evaluation report and a full occupational therapy evaluation may not be needed.
In addition, please provide input on what goals are you seeking to attain with this intervention and if age appropriate, what are the goals that your child is seeking?