New Client Form 2024

Medical Services at our Contract Locations
Please select your child's school

Father's HarborCrossroadsShepherd of the WoodsMainspring Academy
Please select the therapies you would like to receive at your child's school

Occupational TherapySpeech and Language PathologyPhysical TherapyMusic Therapy

Release of Information for In School Services
All in school services require Great Strides staff to openly discuss areas such as treatment, scheduling, etc. Please complete the below Release of Information to provide permission for our staff to discuss necessary information when providing services at your child's school.
Patient/Client Name (First and Last):
Parent/Guardian (Person authorized to release information):
School to which we are permitted to release information:
I authorize Great Strides Rehabilitation

12276 San Jose Blvd. Suite 508

Jacksonville, Florida 32223

Phone: (904)886-3228

Fax: (904)404-7743
To RELEASE medical records contained in the above named patients' record to the above named schoolTo RECEIVE medical or educational records contained in the above named patients' record from the above named school
Specific instructions regarding the release of information. If no specific instructions are provided, you provide authorization for the release of the entire record.
I do hereby that I am the legal guardian of the above named patient and I consent to the disclosure of the specific information listed as it concerns the above named patient of Great Strides Rehabilitation Inc.
Signature

Clear

Diagnosis and Clinical Information
Please list any diagnosis your child has been given, the date of diagnosis and any relevant details.
Does your child have a behavioral diagnosis such as Autism, ADHD, Oppositional Defiant Disorder, etc.?

YesNo
If yes, please upload the diagnostic evaluation completed by a psychologist, psychiatrist, or neurologist.*

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If you do not have a diagnostic evaluation, you will need to obtain one before we can obtain authorization to see your child. Please reach out to your child's physician to obtain a referral for the appropriate provider to complete this evaluation.

If you are seeking OT/PT/ST services, please select 'no' for the above question.
Please describe your top 3 goals for therapy:*
A prescription from your child's primary care physician is required to request services from your insurance carrier. The prescription must contain your child's diagnosis AND the therapy you are looking to begin. Please upload the prescription here.

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Primary Insurance Information *Please bring your insurance card at time of appointment*
Primary Insurance Company:*
Type of Plan

HMOPPOOther
Group Number:*
Member Number:*
Insured Person:*
Insured Date of Birth*

MonthDayYear
Date
Please upload a copy of the front of your insurance card here.*

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Please upload a copy of the back of your insurance card here.*

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I authorize Great Strides Rehabilitation to release of any medical or other information to all of my insurance Carriers or other third party payor"s for the processing of claims or other insurance purposes.
Please Initial:*
Date*

MonthDayYear
Date
Do you have a secondary insurance?

YesNo

Secondary Insurance Information *Please bring your insurance card at time of appointment*
Secondary Insurance Company
Type of Plan

HMOPPOOther
Group Number:
Member Number:
Insured Person :
Insured Date of Birth:

MonthDayYear
Date
Please upload a copy of the front of your insurance card here

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Please upload a copy of the front of your insurance card here

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Your Financial Responsibility
We ask that you verify coverages for the services prescribed by your child's pediatrician. You can do that by calling the member service number on the back of the card.
All accounts are subject to a $5.00 supply charge for supplies and equipment such as toothbrushes, theraputty, modality and infection control supplies, etc. that are not generally reusable and are prepared and used on an individual basis. The cost will be included as a one time charge on your initial visit as permitted by your medical plan.

I acknowledge my understanding and agree that I am legally responsible for my account and all costs associated with the collection of my account. I understand that co-pays, co-insurance, and deductibles are due at the time of service. Any remaining account balances after insurance has been billed will be due within 30 days. If Great Strides employs a collection agency or attorney following default, then all collection fees and reasonable attorney fees may be added to my outstanding balance.

I expressly consent to receiving telephone calls from an automatic telephone dialing system, pre-recorded messages, emails, text messages, or other communication from Great Strides and/or their servicers, debt collection agencies or agents by using any telephone number, email address and/or mailing address with my account or obtained by such entities. I agree that my consent may be revoked by sending written notice to Great Strides or their agents. I agree to arbitrate any claims under the Telephone Consumer Protection Act and I waive any right or ability to bring any class action claims against Great Strides and/or their contractors, servicers, debt collection agencies or agents.

Great Strides and its affiliates strive to provide good faith estimates of what your cost will be for therapy services received at this facility. We will always verify your insurance benefits based on what you provide us at the start of care and discuss with you the findings of what your insurance plan will cover. We will inform you as best we can regarding all insurance benefit information per the guidelines stated in the “No Surprises Act”. This document is posted in our facilities and can also be found online at www.h2health.com.

If you think you’ve been wrongly billed, contact 1-800-985-3059 or visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law
I have read and understand my financial responsibility. I realize and accept responsibility for charges not covered by all of my insurances.
Please Initial :*
Date*

MonthDayYear
Date
Cancellation Policy & Tardiness
Please notify Great Strides Rehabilitation 24 hours in advance if you are unable to keep your scheduled appointment by calling the front desk at 904.886.3228.
For new patients, we are unable to reschedule you if you no show your 1st appointment .
For existing patients, If you have (3) three or more cancellations or no shows in a quarter, you will be charged a $50.00 late fee. In addition, your therapist may discharge your child.
In consideration of other patients and staff members, if you are going to be late for your appointment, please call the front desk at 904.886.3228 to ensure your therapist will still be able to see you. Your appointment may need to be rescheduled.
All therapists are scheduled with back to back appointments, therefore, If you are late dropping off or picking up your child from therapy, there will be late fee of $1.00 per minute.
Please initial that you have read and understand the Cancellation and tardiness policy:*
Who is the person that will handle the financial responsibilites for this child ?*

MotherFatherOther- please list their information below
If other, Please supply their name, address, phone number and email address
I hereby give consent for treatment to be rendered to my child.
Parents Signature:*
Date:*

MonthDayYear
Date
I have been provided the HIPAA privacy Policy *
Parents Signature
Should be Empty:

Basic Demographic Information

Medical Services at our Contract Locations

Release of Information for In School Services

Scheduling Availability

Diagnosis and Clinical Information