Intake Form 2018-07-10T21:32:29+00:00

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690 E. Warner Rd. Ste. 105, Gilbert, AZ 85296  ||  Phone: (480) 820-6366  ||  Fax: (480) 820-0462

NEW PATIENT INFORMATION

  MaleFemale      

    

        Ok to text?YesNo

        Ok to text?YesNo

  *Main contact to send evaluation reports, billing, and other correspondence

Child Lives With:Both ParentsMomDadOther      

        504/IEP:YesNo

  

  

      Order/Script Provided:YesNo

How did you hear about ATS?
Google SearchFacebookWebsitePediatricianFriend/FamilyOther      

Illness/Sickness Policy:

Children need consistent therapy, but on occasion they get sick. When your child has the following symptoms, we prefer you cancel therapy (24-hour notice required when possible).

Fever            Green Runny Nose            Constant Cough            Diarrhea            Vomiting            Extreme Fatigue

Cancellation/No-Show Policy:

To be effective, therapy must be delivered with only short breaks between sessions. Attendance at EVERY session is important for your child to benefit. Therefore, it is crucial that therapy cancellations be avoided if possible. We understand things come up such as illness, family emergencies, vacations etc. Please communicate with your therapist at least 24 hours prior to your therapy appointment, if possible, about these cancelations. Cancellations that occur less than 24 hours before scheduled session will be subjected to a fee of $35.00.

You may cancel an appointment by calling our office at (480) 820-6366 or contacting the therapist directly. More than two cancellations will be reviewed by administration. ATS reserves the right to discontinue therapy for those who have three or more cancellations. If you believe you will need to change session time and day, let your therapist know. If they are unable to accommodate you then please contact our Office Manager to see what other therapist, day and time that may be available.

If you do not call to cancel your therapy session it will reflect as a “No-Show”. With one No-Show you will be able to continue therapy. With two No-Shows, ATS will remove you from the therapy schedule so that we may accommodate another child on our wait list. Please avoid No-Shows and communicate with your therapist.

I, , agree and understand the Illness and Sickness Policy, as well as the Cancellation and No Show Policy.

690 E. Warner Rd. Ste. 105, Gilbert, AZ 85296  ||  Phone: (480) 820-6366  ||  Fax: (480) 820-0462

HIPAA ACKNOWLEDGMENT OF PRIVACY PRACTICES

DOWNLOAD HIPAA NOTICE OF PRIVATE PRACTICES

  

I,   , guardian of   , acknowledge that I have received a copy of the HIPAA Notice of Private Practices from Advanced Therapy Solutions.

I agree and authorize Advanced Therapy Solutions to release my child's Protected Health Information to the following persons to facilitate care. If at anytime you would like to withdraw, make changes, or update the persons listed, please let us know in writing and new form will be provided.

    

    

    

    

Please list any persons who are not permitted to receive any information regarding this child:

Is there any legal documentation stating this?YesNo      *Please note that we may need to view this document for verification

I authorize Advanced Therapy Solutions to contact me in the way indicated below:

Phone:YesNo        

Leave Message:YesNo        

Text Message:YesNo        

Email:        

690 E. Warner Rd. Ste. 105, Gilbert, AZ 85296  ||  Phone: (480) 820-6366  ||  Fax: (480) 820-0462

AUTHORIZATION FOR MUTUAL EXCHANGE OF INFORMATION

PURPOSE: To obtain child’s records and/or coordinating services.

  

I hereby authorize the mutual exchange of protected health information regarding the above-named child between Advanced Therapy Solutions and the following listed below:

    

  

My signature on this facsimile copy, scanned copy, pdf or other reproductions of this document shall be valid and binding. This release is effective for one year from the date of signature. Any person or agency receiving this information is directed to treat it as confidential.

  

690 E. Warner Rd. Ste. 105, Gilbert, AZ 85296  ||  Phone: (480) 820-6366  ||  Fax: (480) 820-0462

INSURANCE INFORMATION

      

      

      

  

  

Primary Medical Insurance:

  

    

      

  

      

Secondary Medical Insurance:

  

    

      

  

      

Check here if parent has DDD, DDD patients still need their primary and secondary insurance listed above:

Financial Policy

I understand and agree that I am ultimately responsible and liable for payment of all charges assessed for professional services rendered and will pay any sum due upon demand. I understand that insurance claim forms will be submitted to my insurance company as a courtesy. I understand that verification of benefits IS NOT a guarantee of payment by the insurance and only done as a courtesy. Please be aware that some insurance companies require that payments for therapy services issued directly to the insured member and not to the provider. Please ensure all checks received are signed over and sent to ATS upon receipt. If an insurance check is cashed accidentally, a personal check will need to be issued to ATS.

I understand and agree that if it becomes necessary to retain an attorney and/or collection agency for the collection of any outstanding charges, whether a lawsuit is filed on my account, I will be responsible for any attorney and/or collection fees and court cost in addition to outstanding balance. Patients authorized for therapy by the Arizona Department of Economic Security, Division of developmental Disabilities, are not responsible for payment of charges.

Cancelation Policy

If you need to cancel an appointment, we request a 24-hour notice. If you cancel within less than 24-hours of your schedule appointment time, you will be charged $35.00. The insurance will not pay for “no shows” or late cancellation charges – theses charges must be paid by the patient by or upon the following session.

Assignment of Benefits

I request that payment of authorized insurance benefits on my behalf go to Advanced Therapy Solutions.

Medical Information Release

I hereby authorize the release of any information, including the diagnosis and the records of any treatments or examinations rendered, to my insurance company or companies or other health care agencies. I also authorize the release of medical records or copies of such and request that they be transferred to Advanced Therapy solutions, 690 E Warner Road Suite 105, Gilbert, Arizona 85296.

  

690 E. Warner Rd. Ste. 105, Gilbert, AZ 85296  ||  Phone: (480) 820-6366  ||  Fax: (480) 820-0462

CASE HISTORY

  

  

  

  

Does your child have a medical diagnosis? (List if applicable)
YesNo      

Has the child received therapy in the past? (Check if applicable)
SpeechPhysicalOccupationalVisionMusicFeedingHabilitationOther

  YesNo

Birth History

Delivery:  VaginalCesarean      

    

Did the child have any difficulties sucking?  YesNo

Was the child a good eater as an infant?  YesNo

Was the mother in good health and nutrition during the pregnancy?  YesNo

Did the mother smoke, drink, or do drugs, during pregnancy?  YesNo

At what age did your child achieve the following:

      

      

      

      

Does your child experience the following:

Poor Attending Skills:YesNo        Easily Distracted:YesNo        Aggressive Behaviors:YesNo

Resistance To Structure:YesNo        Has Social Skill Concerns:        Anxiety:YesNo

Sensitivity To Sound:YesNo        Object To Being Touched:YesNo        Severe Fear Of Something:YesNo

Picky Eater:YesNo

Is there a history of:

Asthma:YesNo        Have an inhaler?YesNo        Seizures:YesNo        Currently experiencing regularly?YesNo

Head Injuries:YesNo        

Family With Learning Disability/Difficulties:YesNo        

Family With Speech/Language Impairment:YesNo        

Family With Hearing Impairments:YesNo        

Recurrent Ear Infections:YesNo        Pressure-Equalized Tube Placed:YesNo        

Hearing Loss:YesNo                Hearing Aids:YesNo

Vision Loss/Correction:YesNo                Wear Glasses/Contacts:YesNo

School Information:

  

Does child perform at grade level in:ReadingMath        504/IEP:YesNo

Consent For Care:

I, , agree and give my consent for Advanced Therapy Solutions to furnish medical care and treatment considered necessary and proper in evaluating and treating my child, , and their conditions.

690 E. Warner Rd. Ste. 105, Gilbert, AZ 85296  ||  Phone: (480) 820-6366  ||  Fax: (480) 820-0462

PATIENT CREDIT CARD ON FILE FOR PAYMENT

  

  

PLEASE READ THE FOLLOWING BEFORE SIGNING:

I have provided Advanced Therapy Solutions my credit card information to keep on file for future use. This means I am authorizing Advanced Therapy Solutions to charge my credit card on the 5th day of each month (or the following business day) for the previous month’s dates of service rendered and/or past due balances. A receipt for payment will be emailed. For appointment that fall after 4:00 PM or on the weekend, it is ATS’ policy that a credit card must be on file for co-pay, co-insurance or payment responsibilities.

690 E. Warner Rd. Ste. 105, Gilbert, AZ 85296  ||  Phone: (480) 820-6366  ||  Fax: (480) 820-0462

PATIENT FINANCIAL POLICY

I understand that I have a relationship with my insurance company and ATS will bill my insurance company as a courtesy to me to offset the therapy charges. I understand that I am responsible for any co-pays, coinsurance payments, and deductibles required by my insurance company at the time of service.

I understand that if my insurance changes, (even if my child is funded by DDD) it is my responsibility to update this information with ATS as soon as possible to avoid delay of payment for therapy services rendered.

I understand that I am ultimately responsible for any bills that are denied by my insurance company for any reason. It is my responsibility to monitor my policy and limitations on coverage. If insurance denies payments, billing staff will attempt to resolve the issue. If my insurance company fails to reimburse after 60 days, I will be responsible to pay for services. Should the insurance company eventually pay, I will be reimbursed.

I understand that if my account becomes unpaid over 60 days, the Provider may stop therapy services until I begin a payment plan. Overdue bills may be sent to collections with collection costs added as allowable by law.

I understand that if I do not have insurance coverage, payment in full is required at the time of services.

I understand that I may pay for my visits with cash, check, Visa, or MasterCard. I understand if my appointment is not during regular business hours, I will be asked to call the office on the next business day to make the necessary payments by phone. I always have the option of leaving a credit card on file with the office to charge for regular fees each week. I understand that if my check is returned for insufficient funds, I will incur an additional charge of $25.

I understand that each year my insurance policy will renew according to my policy renewal date. At that time, I will be responsible to meet my deductible (if applicable) and my payment schedule will need to be changes at that time. I will alert the ATS billing person of the renewal date.

I certify that the information given in this document is correct and changes will be provided promptly. Your signature below acknowledges that you understand and accept these policies.

  

Advanced Therapy Solutions
690 E Warner Road #105
Gilbert, AZ 85296

Office Phone: 480.820.6366
Office Fax: 480.820.0462

Hours of Operation:
Monday to Friday
8:00am to 5:00pm