Pace Pediatric Therapies | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Date of birth

Gender

Reason for care

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues/Emotional Dysregulation Bowel and Bladder Concerns Communication Concerns Developmental Concerns Sensory Processing Challenges Toilet Training Challenges Other

Please explain your reason for contacting and/or your concerns for therapy.

Limited to 600 characters

Billing & Payment

Insurance Coverage

What is your child's insurance coverage?

Please enter your insurance provider & member ID, OR upload photos below.

If you have a primary & secondary policy, please include both.

Insurance card upload

Upload a photo of your insurance card

For clients with private insurance only: PLEASE READ

PACE is an out-of-network provider and does not bill insurance. Payment is due at the time of service. After each appointment, we provide a superbill (a detailed receipt with the information your insurance requires) that you can submit for possible reimbursement. Before your first appointment, you’ll also receive a Good Faith Estimate (an estimate of expected costs) to help you check your coverage.

I understand the superbill process I would like more clarification on the superbill process Not applicable - Medicaid coverage only

Administrative

Who is your child's primary care doctor and/or pediatrician?

How did you hear about us?

Recommended by physician Recommended by friend or family member Found online Other

Client Preferences

Please check before submitting your inquiry.

I consent to being contacted by PACE by phone, email, and/or text message using the information provided.”

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.