Getting Started

Thank you for your interest in EBS Pediatrics! Prior to starting, we will need the following information to begin this process. Make sure you have all of the items on our Check List:

Prescription from your child’s primary care physician with ICD-9 code and frequency of service
Privacy Policy/HIPPA
Current Evaluation
Insurance Information
Medicaid Information
Preauthorization
Any current Plan of Care Documents including IFSP

Patient Form

Parent's Name
Child's Name	(optional)
Address

City, State, Zip	,
Phone Number
Cell Phone
Email
Diagnosis
Type of Service
Other Concerns
Insurance
HMO / Other
Comments