Transfer of Services

To Whom It May Concern:

Type here
My child____________________________________ was receiving services from

Type here
Type name here
________________________________ for his/her therapy needs.  He/She is not receiving therapy services from anyone else at this time.  Therefore, I am requesting my child receive services from your facility.

____________________________________  ___________________

Name of Child          Date of Birth

Type here
Type here

Type here
Type here
Address: ________________________ Medicaid# ______________________

Type here
________________________________ Last Date of Service: _____________

Phone#: ________________________ 

TYPE NAME HERE

TYPE DATE HERE
Signature of Parent/Guardian _______________________________________

Date: __________________________