1 Client Information Name____________________________________ Date of Birth: ______________________________ Parents’ Names: ____________________________________________________________________________ Address: __________________________________________City:___________________Zip:______________ Phone Number: ___________________________ Cell Phone Number: _______________________________ Email: _________________________________________ Communication preference: home cell email Diagnosis (if known): _______________________________________________________________________ Primary Physician: ____________________________ Phone Number: ____________________________ Physician’s Address: ________________________________City:____________________Zip:_____________ Referring Physician (if different): ________________________ Phone Number: ______________________ Please list other specialists working with your child: Name Specialty Phone Number How did you hear about Building Bridges Therapy? _______________________________________________ Insurance Information Primary Insurance Company:___________________________Person Insured:__________________________ Insurance Address: __________________________________________________________________________ Insurance Phone #: _____________________ Policy #: _______________________ Group #: _____________ Secondary Insurance Company:___________________________Person Insured:________________________ Insurance Address: __________________________________________________________________________ Insurance Phone #: _____________________ Policy #: _______________________ Group #: _____________ Medicaid #: _______________________________________Effective Date:____________________________ Family History Mother’s Name: ___________________________________ Date of Birth: ____________________________ Occupation/Employer: _______________________________________________________________________ Father’s Name: ___________________________________ Date of Birth: ____________________________ Occupation/Employer: _______________________________________________________________________ Marital Status: Single Married Divorced Separated Widowed Building Bridges Therapy 2450 Atlanta Hwy Ste 903 Cumming, GA 30040 770-886-6204 fax 678-261-6421 www.buildingbridgestherapy.com 2 Brother(s), Sister(s), or others living with the child: Name Age Why are you seeking the services of Building Bridges Therapy: __________________________________________________________________________________________ __________________________________________________________________________________________ Has your child previously received therapy services? yes no If “yes”, where and when: ____________________________________________________________________ Birth History and Development Is your child adopted? yes no If so, at what age? __________________________ Were there any complications during pregnancy (illness, injury, infection, etc)? If so, please describe: __________________________________________________________________________________________ Were any medications taken during pregnancy or delivery? __________________________________________ Location of Birth: _________________________________ Birth Weight: ______________________________ Was pregnancy full-term? _________________Please describe labor (normal, long, induced, etc): __________ Describe delivery (normal, caesarean, breech, forceps used, etc): _____________________________________ Please list any complications at birth: __________________________________________________________________________________________ Describe any congenital defect: ________________________________________________________________ Does your child have any other medical issues: __________________________________________________________________________________________ Please list any hospitalizations and/or medical procedures you child has had: __________________________________________________________________________________________ Please list current medications: Name Dosage Frequency Reason for Medication Building Bridges Therapy 2450 Atlanta Hwy Ste 903 Cumming, GA 30040 770-886-6204 fax 678-261-6421 www.buildingbridgestherapy.com 3 Please list any known allergies or dietary restrictions: _____________________________________________ Has your child ever had a psychological, developmental, neurological, psychiatric, EEG, or MRI evaluation? If so, why and what were the results? __________________________________________________________________________________________ Speech and Language Developmental History At what age did your child do the following: Say single words: ________Put 2-3 word together: ________What were his/her first words? _______________ Does your child understand or speak another language other than English? _____________________________ Motor Development At what age did your child do the following: roll over: __________ crawl: __________ sit alone: __________ walk: __________ drink from cup: ________chew solid food: _________eat with utensils: ________tie shoe laces: __________ Was the crawling phase prolonged, brief, or almost eliminated? _____________________________________ Please check if your child is able to do the following: Activity Yes No Hop on one foot Skip with both feet Ride a bicycle Jump Rope Cut with scissors Color inside the lines Have consistent hand dominance Educational Information Is your child currently in school? yes no Name of School: ___________________________ What days does your child attend school? ____________________________________________ Does your child receive any services through school? yes no If yes, what services? __________________________________________________________________________________________ Does your child have a current Individual Education Plan? yes no If yes, please provide a copy. Social/Emotional History What are your child’s favorite toys/activities? __________________________________________________________________________________________ Building Bridges Therapy 2450 Atlanta Hwy Ste 903 Cumming, GA 30040 770-886-6204 fax 678-261-6421 www.buildingbridgestherapy.com 4 How does your child play with other children? __________________________________________________________________________________________ Is your child currently enrolled in any community activities? __________________________________________________________________________________________ Is there anything else we should know about your child or family? __________________________________________________________________________________________ Preferred day and time for therapy: _________________________________________________ Signed ___________________________________________________________Date _______________ Parent/ Legal Guardian Relationship Building Bridges Therapy 2450 Atlanta Hwy Ste 903 Cumming, GA 30040 770-886-6204 fax 678-261-6421 www.buildingbridgestherapy.com 5 CHILD’S NAME:_______________________________ DATE OF BIRTH:__________________ FINANCIAL AND INSURANCE POLICY Updated 4/1/2012 Insurance information will be needed before services begin to verify benefits. A copy of your insurance card(s) and driver’s license is required. Benefits will be verified upon receipt of your insurance information and you will be made aware of any estimated out-of-pocket expenses. Information gained from insurance companies during verification of benefits, however, is not guaranteed. Please notify Building Bridges Therapy of any changes in insurance or Medicaid coverage. It is imperative that families are aware of their insurance coverage and their potential responsibilities. We will strive to keep open communication in regards to insurance and payment. Building Bridges Therapy, Inc charges the usual and customary rate for one hour of therapy services. If you do not have insurance coverage for therapy services a payment plan can be arranged. Payment for private pay sessions is due at the time of service. Building Bridges Therapy is an In-Network provider for Aetna, BCBS, United Healthcare, Tricare, and Medicaid. All other insurances will be billed as out-of-network. Unless your child has Medicaid, families are responsible for all co-pays, co-insurances, and deductible expenses. ________parent initials For qualified children under the age of three, the Babies Can’t Wait program will be billed only when all other sources of payment are exhausted. There may be a family cost participation involved with the BCW program, which will be collected at the time of service or billed to the family. I understand that I am responsible for payment of any services in excess of your Babies Can’t Wait IFSP. ________parent initials Katie Beckett Medicaid, SSI Medicaid, Amerigroup, and Wellcare are accepted. We are not contracted with Peachstate. Insurance will always be billed first and Medicaid will be billed secondary unless it is the primary source of payment. Prior approvals are required for therapy services over 8 units per month. Therapists will submit for prior approvals based on need. Services will be administered after approval has been obtained. ________parent initials Building Bridges Therapy, Inc will bill insurance the usual and customary rate for ABA Therapy. I understand if my insurance does not cover ABA Therapy I will be responsible for the private pay rate per one hour of ABA/ therapeutic activity: $60 with BCBA, $40 with behavioral therapist, $35 four hours or more weekly with behavioral therapist. Payment for private pay sessions is due at the time of service. The fee for an initial ABA appointment is $160.00. This appointment will allow initial assessment to take place, as well as development of goals and documentation binder. This assessment is an out-of-pocket expense and payment is expected at the time of service. ________parent initials If payment has not been received within 60 days from the date of service, families will be responsible for the balance. If a family does not pay a bill within 30 days of receipt, there will be a 10% late fee added. ________parent initials Building Bridges Therapy 2450 Atlanta Hwy Ste 903 Cumming, GA 30040 770-886-6204 fax 678-261-6421 www.buildingbridgestherapy.com 6 As in all health-care situations, the client-family is always responsible for payment when all other sources have been exhausted. Therapy services may be put on hold or terminated if there is a problem regarding payment. There is a $25 service fee for all returned checks. Please do not hesitate to contact us regarding questions of billing/payments. We are willing to work with each client to insure a balance between providing therapy services and addressing business issues or concerns. I have read and understand the above billing policy. Signed ___________________________________________________________Date _______________ Parent/ Legal Guardian Relationship CONSENT FOR PAYMENT I authorize Building Bridges Therapy, Inc. to bill my insurance company for direct reimbursement of therapy services rendered to my child. I assign benefits for filed claims to be paid to Building Bridges Therapy, Inc and will turn over any payments sent directly to me by my insurance provider that were intended to cover the therapy services provided by Building Bridges Therapy. I understand that I am responsible for payment of any services not paid by insurance. Signed _________________________________________________________ Date ________________ Parent/ Legal Guardian Relationship ATTENDANCE POLICY Building Bridges Therapy, Inc’s policy states that we require a 24 hour notice for cancellations. After a onetime occurrence, a $25 fee may be charged for each missed therapy appointment. We know that sickness occurs; therefore, if you think that your child is sick the night before, please call us and give us notice so we can plan accordingly. If your child is fine the next day, we will make every effort to reschedule. In the event of a cancellation, please make an effort on your part to reschedule as we want your child to benefit from his/her therapy. Additionally, if your child misses 3 consecutive weeks of therapy, we will make every attempt to hold that slot, but cannot guarantee this with an extended absence. We at Building Bridges Therapy strive to meet the scheduling needs of every family. If your therapy time does not work for you, please let us know. The Board of Health considers the following signs to indicate communicable disease/illness: Vomiting Fever over 100 degrees Diarrhea Sore throat Rash /Swelling Red, or running eyes Please be sure your child is symptom free for 24 hours before resuming therapy. Parent/Guardian Signature: ______________________________________ Building Bridges Therapy 2450 Atlanta Hwy Ste 903 Cumming, GA 30040 770-886-6204 fax 678-261-6421 www.buildingbridgestherapy.com 7 CONSENT FOR TREATMENT I, ______________________ (caregiver’s name), knowing that _______________________ (child’s name) has a diagnosis requiring physical, speech, occupational, and/or ABA therapy treatment, voluntarily consent to such care for the aforementioned child by the therapist doing business for Building Bridges Therapy, Inc. as may be beneficial in the professional judgment of this child’s therapist. I consent to care and treatment that falls within the scope of practice as defined by the State of Georgia for each discipline. I understand that treatment will involve physical participation on the part of the patient which may involve risks of injury. You are responsible for making your therapist aware of any changes in your child’s physical or mental status. I acknowledge that no guarantee has been made to me as the result of evaluation and/or treatment. Building Bridges Therapy is a teaching facility and supervised students or volunteers may participate in your child’s treatment session. Signed ______________________________________________ Parent/Guardian Relationship Date ___________ In my absence, I consent that_______________________ (child’s name) may receive therapy under the care of: _____________________________________________________________________________. (List all caregivers, teachers, daycare providers, etc. that may be present during therapy in your absence.) Signed _______________________________________________ Parent/Guardian Relationship Date _________ CONSENT TO EXCHANGE INFORMATION I authorize Building Bridges Therapy to release or communicate necessary and pertinent information to physicians, case managers, and insurance companies for my child _____________________. Approved information may be given to, received from, and discussed with the following people directly related to my child’s care. Approved information includes written documentation and/or verbal discussion. Other Therapists: ___________________________________________________________________________ School Name: _____________________________________________________________________________ Please list any others:________________________________________________________________________ Signed _______________________________________ Printed Name ____________________Date ________ Parent/Guardian NOTICE OF PRIVACY POLICY I have read, understand, and agree to the Building Bridges Therapy Notice of Privacy Policy. I understand I may request a copy of this policy at any time. I consent to receive communication regarding my child’s therapy via (circle all that apply) phone messages at home or cell phone, email address: __________________________ Signed _______________________________________ Printed Name ____________________Date ________ Parent/Guardian Building Bridges Therapy 2450 Atlanta Hwy Ste 903 Cumming, GA 30040 770-886-6204 fax 678-261-6421 www.buildingbridgestherapy.com