Patient Information

Patient Information

Please fill in the form below
Name*

First NameMiddle NameLast Name
Sex
Date of Birth*

MonthDayYear
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
If Patient is a Child

Please complete the following section:
Parent #1 Name:*

First NameLast Name
Parent #1 Email*
example@example.com
Parent #1 Contact Number:*

Area CodePhone Number
Parent #1 Employer:*
Parent #2 Name:

First NameLast Name
Parent #2 Email
example@example.com
Parent #2 Contact Number:

Area CodePhone Number
Parent #2 Employer:
Marital Status*
If parents are divorced, separated, or unmarried, please fill out this section: Who has physical custody?
Are there any legal restrictions that would restrict the non-custodial parent from consenting to treatment for the child or from obtaining information about the child’s treatment?
If yes, please explain and provide a copy of any legal paperwork that supports this restriction:
If the patient is an adult

Please complete the following section:
Email
example@example.com
Phone Number

Area CodePhone Number
Employer
Name of Spouse (if applicable)
Spouse Phone Number (if applicable)

Area CodePhone Number
Physician Information
Patient Physician Name:*
Physician Practice Name:
Physician Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Phone Number:*

Area CodePhone Number
Consents
Consent for Treatment: I consent for therapists employed by GASLC and/or contracted therapists working for GASLC to provide my child or myself with speech-language, occupational, and/or physical therapy including assessment and intervention.*

YES
Initial Here:*

Clear
As the parent or legal guardian of the patient, I give authorization for the person(s) named below to bring my child to the evaluation/therapy sessions in my absence. I also give permission for the therapist to discuss the current treatment procedures and/or release records to the people listed below. This is in compliance with HIPAA 1996 and is designed to safeguard the privacy and security of the named patient’s health information. Parent #2*

YESNO
Additional adults allowed to bring my child to therapy:
Consent to Email Protected Health Information: I consent for employees and contracted therapists working for GASLC to send any and all protected health information regarding mychild or myself via email, which includes but is not limited to: evaluations, treatment notes, weekly session updates, progress notes,etc.*

YESNOOther
Photo Release: I give permission for my child’s picture to be used on our bulletin boards, website, and Facebook.*

YESNO
Cancellation/Termination Policy: I understand that GASLC reserves the right to charge a fee for any appointment that is not kept or not cancelled by giving 24 hours notice. Unforeseen circumstances are anticipated and will be handled on a case by case basis. If you plan to dismiss your child or yourself from therapy, a 2-week notification is REQUIRED unless otherwise agreed upon. Should you choose to end treatment without two-week notification, you will be responsible for paying for all services that would have been provided in those two weeks.*

YESNO
Cancellation/Termination Policy: I understand that I must attend 75% of scheduled visits (regardless of cancellation or no-show status) to keep my regularly scheduled therapy time.*

YESNO
Initialing below notifies GASLC that I agree to the above cancellation and termination policies. Initials*
Financial Responsibility Information
Who is responsible party for this account? *
Relationship to patient: *
Date of Birth of responsible party: *
SSN of responsible party: *
Insurance/Medicaid Information
Is the patient covered by Insurance:*

YESNO
If patient is covered by insurance complete the following information:

Primary Insurance Company:
ID #: Group #:
Primary Insured:
Relationship to Patient:
DOB of Primary Insured:
Customer Service Provider Phone Number:
Take Photo of Front of Insurance Card. If you cannot take a photo, you can upload a file in the next question and take a blank photo.*
Upload a photo or file of the front of your insurance card if you did not take a photo.

Browse Files

Cancelof
Take Photo of Back of Insurance Card*
Upload a photo or file of the front of your insurance card if you did not take a photo.

Browse Files

Cancelof
Is the patient covered by secondary insurance:*

YESNO
If patient is covered by secondary insurance, complete the following information:

Secondary Insurance Company:
ID #: Group #:
Primary Insured:
Relationship to Patient:
DOB of Primary Insured:
Customer Service Provider Phone Number:
I understand that if I have BOTH primary and secondary insurance policies that this makes my claims subject to coordination of benefits and subject to the rules and regulations of each separate policy. Initials*
Is the patient covered by Medicaid:*

YESNO
If patient is covered by Medicaid complete the following:
Medicaid #:
Take Photo of front of Medicaid Card:
Assignment and Release
I, the undersigned, certify that I (or my dependent) have insurance coverage with * and assign directly to Greater Atlanta Speech and Language Clinics, Inc. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize Greater Atlanta Speech and Language Clinics, Inc. to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Signature*

Clear
Relationship to Patient:*
Date*

MonthDayYear
Follow Us on Facebook:
Should be Empty:

Patient Information

If Patient is a Child

If the patient is an adult

Physician Information

Consents

Financial Responsibility Information

Insurance/Medicaid Information

Assignment and Release