Client Name: First Name* Last Name* Client DOB: Client DOB* Gender at Birth: Gender at Birth* Gender Identity: Gender Identity Pronouns: Pronouns Parent Name: First Name* Last Name* Parent DOB: Parent DOB* Parent SSN: Social Security # Phone Number: Area Code and Phone Number* Current Address: Street Address* Apt # City* State* Zip* Email: Email* Emergency contact: First and Last Name relationship area code and phone Number
Physician Name/Practice: Physician name and practice name* Phone Number: Area Code and Phone Number Fax Number: Area Code and Fax Number Do you have Medicaid? Yes/No* Medicaid Number: Medicaid Number (Type N/A If Not Applicable)* Do you have private insurance? Yes/No* Private Insurance Company Name: Insurance Co (Type N/A If Not Applicable)* Insurance Phone Number: Area Code and Phone Number Policy ID : Policy ID Number (Type N/A If Not Applicable)* Group : Group Number (Type N/A If Not Applicable)* Policy Holder Name: Policy Holder Name* Policy Holder DOB: Policy Holder DOB (Type N/A If Not Applicable)* Is the policy holders address the same as above? Yes/No* If no, what address? Street Address City State Zip Any other insurance? If No, type NA. If Yes, include Company, ID number, Group, Area Code and Phone Number, policyholder name and date of birth*
Referral Source How did you hear about us? Is there a particular therapist you'd like to see? therapist name What day/time works for you on a consistent basis? Day(s)What days work best* Time(s): What times work best?* What locations work best for you? Home Clinic School/Daycare* list name of school/daycare and location Reason(s) for seeking therapy? Please tell us why you need us* Are there any languages other than English spoken in the home?List any languages besides English Additional Information (Previous Services, Diagnoses, etc): list any other information that you think will be helpful for us to know For questions, Please call (704)846-0262
Early Bird Consent Forms
Client Name: First Name* Last Name* Client DOB: Date* Name Of Person Filling Out Form: First Name* Last Name* Relationship to Child: Relationship*
I give my voluntary consent for Early Bird Developmental Services to use and disclose health information regarding Blank* to carry out treatment, payment and health care operations. In addition to sharing health information with my insurance company/Medicaid if requested and acquiring physician orders, I authorize Early Bird Developmental Services to exchange health information with the following agencies or person(s): Blank* (list out any agencies with whom we can exchange information such as your pediatrician, school, etc.)
Consent for Treatment, Payment, and Operations
By signing this form, I am consenting to Early Bird Developmental Services' use of and disclosure of my child's protected health information for treatment, payment, and health care operations. I understand that I do not have to consent to the use or disclosure of my child's protected health information for treatment, payment, and health care operations, but if I do not consent, Early Bird Developmental Services may refuse to provide me health care services. I understand that I can request more information at any time about how Early Bird Developmental Services uses or discloses protected health information to carry out treatment, payment, and health care operations. I understand that I can revoke this consent at any time. This consent is effective until the above-named client is discharged by Early Bird.
I fully understand this document and give my consent.
Signature: Signature* Relationship to Client: Relationship* First Name* Last Name* Today's Date: mm/dd/yyyy*
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This is a summary. For the full text of this notice visit www.earlybirdonline.com. For more information or assistance, or to request a printed copy of the full text this notice, contact Robert Kornfeld, Director of Operations, 704-9995-2929 or email@example.com
You have the right to:
You may permit - or deny us permission - to use and share your information in certain ways. Without express written permission WE WILL NOT:
Our Uses and Disclosures
We may use and share your information as we:
I acknowledge by signing below that I have received and read/had explained to me Early Bird Developmental Services' Notice of Privacy PracticesSignature First Name* Last Name* Relationship to Client: Relationship* Today's Date: mm/dd/yyyy*
Client Guide to Company Policies
FINANCIAL RESPONSIBILITY, BILLING & PAYMENT
It is your responsibility to pay for all services rendered. We are in-network with most major insurance companies and will file our claims with your insurance company or another payer for services rendered on your behalf. We will verify your insurance benefits with your carrier and provide you with a good-faith estimate of your out-of-pocket costs for our services, but it is important to understand that we do not guarantee this information. Insurance companies do not guarantee payment; payment is determined at the time we file each claim (each time a service is provided).
Knowing your benefits is ultimately your responsibility, and we strongly encourage you to call your insurance company directly or use an online portal to review your benefit information as it applies to our services. If you have a change in insurance or Medicaid status, you must inform your therapist or call the office immediately at 704-846-0262.
Once we have received a reply from your insurance or other payer for each claim, we will bill you on the 15 th of each month for your portion of our charges, if any. (This process can take several weeks.) Please do not pay your therapist directly.
If you prefer, an interest-free Equal Payment Plan is available. You may pay your out-of-pocket costs in 12 or 24 equal monthly installments. A credit/debit/HSA will be kept on file and automatically charged each month. You will get a receipt for each payment by email and continue to receive monthly statements showing all charges and credits.
To request paperless statements or set up an Equal Payment Plan, please contact Bob Kornfeld at 704-995-2929 or firstname.lastname@example.org. To pay your bill online go to www.earlybirdonline.com and look for the “Make Payment” tab at the top of the page. Unpaid balances may incur late charges or lead to suspension of services. Delinquent balances or returned checks may be referred for collection and incur additional costs.
Please initial here to indicate that you have carefully read and understand Early Bird’s Financial Responsibility Policy:
MISSED SESSIONS & CANCELLATIONS
It is Early Bird’s policy to provide Medicaid members with limited English skills the language assistance necessary in order to afford them meaningful and equal access to the Medicaid benefits and services to which they are entitled, in accordance with Title VI of the Civil Rights Act of 1964 (42 U.S.C. §§2000 et. seq.) and regulations pursuant thereto (45 C.F.R Part 80).
YOUR QUESTIONS AND CONCERNS
In order for us to be successful in our intervention, we must work together and have an open and honest relationship. If you are having difficulty regarding scheduling appointments, treatment techniques used, or any other aspect of the therapeutic process, please express your concerns to your therapist, or directly to Early Bird Clinical Director Sherry Kornfeld at email@example.com or 704-846-0262.
I acknowledge by signing below that I have read and understand the Early Bird Client Guide to Company Policies:
Name: First Name* Last Name* Today's Date: Date*
Consent for In-Person Services during Pandemic
This document contains important information about our decision (yours and mine) to resume in-person services during the COVID-19 pandemic. We will return to teletherapy services if lockdown orders are again imposed by local, state or federal authorities, if other health concerns arise, or at any time you or I feel it is safer to do so.
By Signing below, I acknowledge that there are risks associated with in-person services during a pandemic.
Our responsibilities to minimize exposure
To begin or resume in-person services, I agree to take certain precautions which will keep everyone (you, me, our families, and other patients) safer from exposure to the virus that causes COVID-19. If we do not adhere to these safeguards, it may necessitate a return to teletherapy services.
This agreement supplements the original Consent for Treatment, Payment, and Operations that I signed at the start of our work together. Your signature below indicates that you agree to the above conditions.
Caregiver Signature: Signature* Printed Name: First Name* Last Name* Today's Date: mm/dd/yyyy*
Tele-Health Informed Consent Form
Signature: Signature* Relationship to Child: Relationship* Today's Date: mm/dd/yyyy*