NEW PATIENT INTAKE FORM PATIENT INFORMATION Patient’s First Name * First Middle Initial MI Last Name * Last Gender * Select Male Female Date of Birth: * Social Security Number Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal REFERRING SOURCE Physician Full Name * Full Name Phone * Fax PARENT|LEGAL GUARDIAN First Name Parent | Legal Guardian First Name/Middle Name Last Name Parent | Legal Guardian Last Name Relation to Client Relation to Client Phone Email INSURANCE *** MUST BE FILL *** PRIMARY INSURANCE * PHONE POLICY NUMBER GROUP POLICY HOLDER RELATION TO PATIENT POLICY HOLDER’S DAY OF BIRTH POLICY HOLDER’S SS# POLICY HOLDER’S EMPLOYER REASON FOR REFERRAL | DIAGNOSTIC SECONDARY INSURANCE PHONE POLICY NUMBER GROUP POLICY HOLDER RELATION TO PATIENT POLICY HOLDER’S DAY OF BIRTH POLICY HOLDER’S SS# POLICY HOLDER’S EMPLOYER REASON FOR REFERRAL | DIAGNOSTIC YOUR HEALTH CARE PROVIDER, INSURER, OR PLAN MAY REQUIRE A PHYSICIAN REFERRAL OR PRIOR AUTHORIZATION AND YOU MAY BE OBLIGATED FOR PARTIAL OR FULL PAYMENT FOR SERVICES PROVIDED. AUTHORIZATIONS and ACKNOWLEDGEMENTS HIPPA: Notice of Privacy Practice Patient Name * By signing this statement you are acknowledging that you have had the opportunity to receive HIPAA Notice of Privacy Practices: Signature * Clear Signature Parent/Legal Guardian or Self Date * INSURED OR AUTHORIZED PERSON’S SIGNATURE: I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby assign and request payment to be made directly to “Carrousel Health Care Corporation,” for services rendered to my child. * Clear Signature: Date * PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE: RECORDS RELEASE * Clear I hereby authorize the release of any necessary information to process insurance claims, including medical and billing information, as well as to discuss the child’s case information with other Therapists working within the building structure of Carrousel Health Care Corporation to/from, from/to the referring physician, Therapist Co-workers and insurance company. Date * Scheduling (for first time appointments) Please list all times your child would be available for their appointment/s. Some times are more difficult to schedule than others. It will assist us with scheduling your child quicker if you give us as many options as possible. We will do everything we can to work with you. Thank you for your assistance. Please list all days and times your child is available: CHILD CASE HISTORY FORM GENERAL INFORMATION: CHILD’S NAME: Full Name Date of Birth: Age: Person Providing the Information: Full Name Today’s Date * Sex: * Select Male Female Child’s Address Child's Address Child's Address Child's Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Physician: Phone: Referred By: The family requests that results of this evaluation should be sent to: Please complete consent form to allow us to do this. Name Address: Name Address: Please describe reason for evaluation: Which services are you requesting? Medical Care Services Psychiatric Mental Health Counselor Psychosocial Rehabilitation Services Please list diagnosis, if any, who diagnosed, and when your child was diagnosed: THERAPY PRECAUTIONS Please be specific Does your child have any food allergies? No Yes, Please list.Yes, Please list. If your child has Down’s Syndrome, has he/she been diagnosed with Atlantoaxial instability? No Yes. Are there any movement restrictions?Yes. Are there any movement restrictions? Are there any precautions not listed above that we should know about. No Yes. Please describe.Yes. Please describe. FAMILY HISTORY Father’s Name: * Full Name Age: Occupation: Mother’s Name * Full Name Age Occupation Were there any illnesses, injuries, bleeding, or any complications during this pregnancy? No Yes. DescribeYes. Describe Are Parent’s? Living Together Separated Divorced (chose One) Have there been any instances of the following in your immediate or extended family members: ADHD Learning Disability Communication Disorder Autism/PDD Hearing Loss (Check All that Apply) PREGNANCY AND BIRTH HISTORY Were there any illnesses, injuries, bleeding, or any complications during this pregnancy? No Yes. DescribeYes. Describe Was this pregnancy full-term? YES No. Please give gestational age and weight at time of delivery.No. Please give gestational age and weight at time of delivery. Was labor and delivery normal? YES NO Did your child experience jaundice? YES NO Was there need for oxygen or respiratoryassistance? YES NO Were there difficulties with feeding? YES NO Did your child bottle-feed or breast feed? YES NO Did your child have difficulties sucking? YES NO Number of Siblings Select 1 2 3 4 5 6 7 8 9 10 MEDICAL HISTORY Has your child had any of the following illnesses? Meningitis YES NO COMMENTS:COMMENTS: Chicken Pox YES NO COMMENTS:COMMENTS: Seizures YES NO COMMENTS:COMMENTS: Frequent Ear infections YES NO COMMENTS:COMMENTS: Excessive vomiting or reflux. YES NO COMMENTS:COMMENTS: Cleft Palate YES NO COMMENTS:COMMENTS: Does your child have vision problems? YES NO COMMENTS:COMMENTS: Does your child use any adaptive equipment? YES NO COMMENTS:COMMENTS: Is your child on any medications? YES NO Please list.Please list. Please describe any pertinent medical conditions not mentioned above. GROWTH AND DEVELOPMENT What age did your child: Roll over from stomach to back? Roll from back to stomach? Sit independently? Walk Talk (words/sentences) PATIENT SERVICE AGREEMENT NAME OF PATIENT * Date of Birth * PRINT NAME PARENT/LEGAL GUARDIAN Date * Patient Service Agreement between below “Parent/Legal Guardian” and “Therapy” * Clear SIGNATURE: PARENT/LEGAL GUARDIAN New Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operations I, * ( the term “I” refers to the Parent/Legal Guardian of child) understand that as part of my healthcare, “Carrousel Health Care Corporation,” originates and maintains paper and/or electronic records describing “my” (the term “my” refers to parent and/or child) health history, symptoms, examinations and test results, diagnoses, treatment, and any plans for future care of treatment. I understand that this information serves as: -A basis for planning my care and treatment, -A means of communication among the many health professionals who contributes to my care, -A source of information for applying my diagnosis and surgical information to my bill, -A means by which a third-party payer can verify that services billed were actually provided, and -A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcareprofessionals. I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges: -The right to review the notice prior to signing this consent, -The right to object to the use of my health information for directory purposes, and -The right to request restrictions as to how my health information may be used or disclosed to carry out treatment,payment, or healthcare operations. I understand that “Therapy,” is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations. I further understand that “Therapy,” reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should “Therapy,” change their notice, they will send a copy of any revised notice to the address I’ve provided (whether U.S. mail or if I agree e-mail). I wish to have the following restrictions to the use or disclose of my health information: I understand that as part of this organization’s treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax and/or e-mail. I fully understand and accept the terms of this consent. * Clear Parent/legal Guardian’s Signature Date * FOR OFFICE USE ONLY Consent received byConsent received by Consent refused by patient, and treatment refused as permitted. Consent added to the patient’s medical record onConsent added to the patient’s medical record on HIPPA Release Form I, * Print Name Of Parent/Guardian Parent/Guardian of Patient: * give permission to “CARROUSEL HEALTH CARE CORPORATION.” and all employees to discuss and/or receive medical information including medical records concerning any and all aspects of patient’s previous healthcare by a doctor, physical, occupational or speech therapist, or other medical professional. This release is required to obtain medical information according to the privacy rule detailed in HIPPA (The Health Insurance Portability and Accountability Act of 1996). Patient Name: * Patient Date of Birth: * Patient’s Social Security: Parent/Guardian’s Name (Printed): Parent/Guardian’s Signature: * Clear Date * Credit Card Agreement All parents and guardians are responsible for paying their child’s co pay and deductibles, set by their Insurance Company. These fees are nonnegotiable. Unless otherwise specified, we will collect these fees every session. We have made this process easier by accepting Visa card, Master card, American Express card, and Discover card. By signing below it is agreed that your credit card number will remain on file and “Carrousel Health Care Corporation” will charge that credit card only in the event that your child attends his or her therapy session. A receipt will be provided to you for all charges applied. We hope this makes everything easier for you to keep track of your fees. Thank you, Parent/Guardian Name (Printed) Title Parent/Guardian Signature Clear Date Credit Card # MC/Visa/American/Discover Expiration Date If you are human, leave this field blank. Submit
