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FORMS



Instructions for Intake Form
Patient Registration Form
Child Case History Form
HIPPA Consent and Release Form
Health Insurance Benefits Worksheet
Occupational Therapy Speech Therapy Physical Therapy Our Staff Contact Us Resources

We look forward to the opportunity to assist you!

If you would like to schedule an appointment at our Eagan or Apple Valley clinics, please call 651-994-9644. For general questions we welcome you to call either site.

For your convenience, you may download and print the forms on the left prior to your appointment. To view a form, click on the name of the file to open it (Adobe Acrobat Reader needed). You will then be able to print the form.

We currently participate with the following plans. Our participation, allows for the highest benefit of coverage for our clients, however, this does not guarantee coverage. Please contact your insurance company regarding your specific benefits.
BLUE CROSS BLUE SHIELD
CCS
EMPLOYER PROVIDER NETWORK
TWIN CITIES LOCAL UNIONS
MEDICA
SELECT CARE
PREFERRED ONE
PATIENT CHOICE
WAUSAU
UNITED HEALTH CARE
AETNA
ONE HEALTH
AMERICA'S PPO
HEALTHEZ
HEALTH PARTNERS
MINNESOTA HEALTH CARE
PROGRAMS (TEFRA/Medical
Assistance)
U-CARE
OTHERS

*This is not a guarantee of coverage. Please check with your insurance to determine benefit coverage.











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