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NEURODEVELOPMENTAL THERAPY SERVICES , INC.

Northwest (Clay & Beltway)
4423 Shadowdale Lane
Houston, Texas, 77041-8718
Ph: 713.466.6872
Fax: 713.466.9547

West (Katy)
1935 Avenue C
Katy, TX 77493
Ph: 281.392.4221
Fax: 281.392.4225

Client Insurance Information

Your responses will be regarded as confidential, as is any other information you may give.

CLIENT INFORMATION:



RESPONSIBLE PARTY INFORMATION:



INSURANCE INFORMATION:





Assignment of Benefits: I hereby authorize payment to Neurodevelopmental Therapy Services for treatment of my child for therapeutic services.





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