Contact

Requests for support may be submitted to infotcpa@gmail.com . Please include the following information in the message.

 Date______________

 Name of applicant______________________

Date of Birth____________

Diagnosis__________________________

________________________________

Address___________________________

City________________________

State OK     Zip code______________ 

Home phone__________________ 

Cell # ______________________

 Email address_________________________

 Mother/Guardian_______________________

 Employer____________________________ 

Work phone______________________

Annual Gross Salary____________________                       Send a copy of your 1040 tax form

Father/Guardian________________________

 Employer____________________________ 

Work phone______________________

Annual Gross Salary____________________                       Send a copy of your 1040 tax form

Other Family Income_______________   

Monthly Medical Expenses______________

 Other Expenses Related to Diagnosis ______________________________

# Adults in the Home_________            # of Children in the Home___________

Name of Health Insurance Company/Medicaid/Medicare_______________

Policy/Group #_______________________

 Referring Physician____________________

Phone Number_____________

Referring Therapist____________________ 

Phone Number_____________

Other Referral________________________

Phone Number_____________

Please tell us what services you are requesting and the cost for each service:

Physical Therapy:

Eval $_______  # of visits _____

Cost per visit $______Total cost for PT $_________

Occupational Therapy:

Eval $_______ # of visits______

Cost per visit $______Total cost for OT $________

 Speech Therapy:

Eval $_______ # of visits______

Cost per visit $______Total cost for ST $_________

 Equipment/Splints/Orthotics:

 Please list specific  type(s):___________________

___________________________________

 Total cost $_______________

 Please list any other assistance requested:___________

___________________________________

___________________________________

 ___________________________________ 

___________________________________

 ___________________________________

 

Has TCPA helped you before?    Yes    No            

If so, please list date:_________________

 

For Office Use Only:

Date:________________

Membership Action:___________________________