AOT & CST Intake Form
Patient's name
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First Name
Last Name
Patient's Date of Birth
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Type of Therapy
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Occupational Therapy
Physical Therapy
Speech Therapy
Location of Services
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160 N NC 241 Hwy, Beulaville
1506 Wayne Memorial Drive Ste D, Goldsboro
101 N Plain Rd, Jacksonville
447 Venture Drive Ste D, Smithfield
1638 Military Cutoff Road, Wilmington
145 Nashville Commons Drive, Nashville NC
Please check my address to see if home/daycare/private school services are available (Johnston/Wilson Counties)
How did you hear about us?
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Google
Social Media
Family Member/Friend
Billboard
Physician
Insurance
Other
If family or friend referred you, you may list them here:
Email Address:
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What are your biggest concerns:
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Scheduling Preference:
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7:00 am - 9:00 am
9:00 am - 11:00 am
11:00 am - 1:00 pm
1:00 pm - 3:00 pm
3:00 pm - 5:00 pm
5:00 pm - 7:00 pm
I am flexible with scheduling and can accommodate what is available
Preferred day (days) of the week for therapy:
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Have you had any therapy this calendar year?
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Yes
No
For adult patients, have you had any home health services in the last 90 days?
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Yes
No
For pediatric patients, do you have a history of therapy?
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Yes, has had therapy and recently discharged
Yes, has had therapy in the past but not recently
No therapy history
If a pediatric patient, please list primary guardian. If an adult patient, please list additional contact name and phone number:
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Phone Number
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Please enter a valid phone number.
Alternate Phone Number
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Please enter a valid phone number.
Does your phone number accept text message reminders?
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Yes
No
Our cancellation policy states if you cancel within 24 hours of a scheduled appointment (excluding sickness or emergency) you will be charged a $50 missed visit fee directly to patient, not to insurance. By signing our form you agree to our cancellation policy.
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Yes
Financial Responsibility to Pay for TherapyAs a private practice (not funded by a governmental entity) we rely on insurance & patient copays to operate. We will file all insurances and are in network with most insurances. If you have a commercial insurance that has a copay per session or a deductible to meet prior to insurance covering service, you are required to put a card on file and the patient responsibility will be run after insurance has processed. We are able to provide a quote; however what the insurance quotes us is not always correct and they do not guarantee coverage. We are unable to give you prior notification before the card is run--please be mindful when placing a card on file, you are expected to have the funds to pay your portion for therapy services. Please understand before signing up for services that if you are unable to pay your copay or pay the deductible your insurance requires, we are unable to provide these services at a reduced rate or for free. Thank you for your cooperation.
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Yes, I understand that if I have a patient responsibility to pay for therapy services that I am agreeing to place a card on file to cover my portion of therapy services--this policy also covers missed visits/improper cancellations..
Photo/Video ReleaseWe are active on social media and enjoy sharing patient/families journey with therapy/rehabilitation. Would you allow us to share pictures/videos of you (or your child if pediatric patient) during therapy?
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Yes, I consent to having my picture/video shared on ATNR's social media/website
No
Patient Consent
I am authorizing Advantage Therapy & Rehabilitation [AT&R] and/or Coastal Speech Therapy [CST] as the preferred provider to provide occupational, physical, and/or speech therapy services to the patient listed above. At any time, I have the right to refuse treatment by notifying the provider of such decision. Our provider offices may also terminate services at anytime by giving notification and reason for such decision.\I am requesting that payment of private insurance, medicare/medicaid be made to AT&R and/or CST for therapy services to the patient listed above. I authorize any necessary protected health information of mine be released to insurance companies in determining payment and authorization for services. I agree to pay in full for all services provided by AT&R and/or CST for any remaining balance due after insurance has been billed.*I understand that it is my responsibility to notify AT&R and/or CST of any changes with insurance and/or primary care physician. I understand that I am held responsible for any amount not covered by the insurance related to these changes.
HIPAA Policy
I understand that AT&R and/or CST will only disclose my protected health information for treatment purposes or obtaining payment for therapy services. I acknowledge this use and disclosure of my personal health information by signing below. I hereby authorize the mutual exchange of information regarding the above named person between AT&R and/or CST between the child's primary doctor and any other individuals or agencies listed below.This patient's information may be used by the person(s) and/or agencies I authorize for medical treatment, consultation, billing, or other purposes. This authorization shall be in force and effect while patient is being treated by AT&R and/or CST. I understand that I have the right to revoke this authorization in writing at any time.
Additional individuals/organizations other than primary guardians you would like us to release information to:
Primary Care Doctor (name & facility):
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Primary Insurance:
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Please Select
Health Choice(under age 19 only)
Medicare
BCBS
Cigna
Medcost
Tricare SELECT
Tricare PRIME (requires authorization prior to first appointment)
VA (requires authorization prior to appointment)
Workers Compensation
UHC (out of network for OT/PT)
Aetna (out of network for OT/PT)
Medicaid (above age 21) (we are unable to accept if this is the primary insurance)
Medicaid
Medicaid Ameriheatlth Caritas
Medicaid Carolina Complete
Medicaid Healthy Blue
Medicaid United Health Care
Medicaid WellCare
Other
Subscriber ID (put zeroes for workers comp)
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Subscriber's name:
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Subscriber's DOB:
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Secondary Insurance (if applicable):
Please Select
Health Choice(under age 19 only)
Medicare
BCBS
Cigna
Medcost
Tricare SELECT
Tricare PRIME (requires authorization prior to first appointment)
VA (requires authorization prior to appointment)
Workers Compensation
UHC (out of network for OT/PT)
Aetna (out of network for OT/PT)
Medicaid (above age 21) (we are unable to accept if this is the primary insurance)
Medicaid
Medicaid Ameriheatlth Caritas
Medicaid Carolina Complete
Medicaid Healthy Blue
Medicaid United Health Care
Medicaid WellCare
Other
Secondary Subscriber ID:
Other individuals or agencies who you would like is to. release information to:
If you have a prescription, please upload a picture here:
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Choose a file
Cancel
of
Please upload a picture of the front and back of your insurance card:
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Cancel
of
Electronic Signature
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Clear
Date of Signature
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Month
-
Day
Year
Date
Please continue to complete our preferred provider form if this is a pediatric patient that has recently received services at another facility
Previous provider's name/company (be specific):
By Signing below, you agree that Advantage Therapy & Rehabilitation is the preferred provider for OT & PT services and Coastal Speech Therapy is the preferred provider for speech therapy services for the pediatric patient. By signing below you agree that the previous provider has been made aware of the change.
Relationship to patient:
Electronic Signature for Preferred Provider form:
Clear
Please verify that you are human
*
Submit
Should be Empty: