Therapy Matters, INC. Therapy Intake Form

We are excited to start your service and we welcome you to our Therapy Matters, Inc. family!

Please follow us on our social media pages and participate in surveys and family events - we are here for you!

If any special accommodations can be made, TMI will go above and beyond to try and accommodate our special families.

Consistent with the legacy of TMI's founder, “Live in the moment and BE the miracle!”

Client's Name:*

First Name Middle Name Last Name

Client's Address:*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Home Phone Number:*

Area Code Phone Number

Cell Phone Number:*

Area Code Phone Number

Do you consent to receiving text messages from Therapy Matters, Inc. regarding scheduling and other important issues? Your privacy is our concern, and we will never sell your information. At any time, you may also opt-out of text messaging; however, it is a great way to stay up to date with your program.*

YesNo

Which is the best # to reach you at?*

Can we leave a detailed message on this number?*

Guardian's Name:*

First Name Middle Name Last Name

Guardian's Relationship*

E-mail:*

Patient Birth Date*

Month Day Year

Patient Sex:*

MaleFemale

Primary Care Physician:*

Physician's Phone Number:*

Area Code Phone Number

Physician's Fax Number

Area Code Phone Number

Patient's Medications*

How did you hear about Therapy Matters?*

Contact:*

First Name Last Name

Phone Number:*

Area Code Phone Number

Relationship:*

Please tell us about the client. (likes, dislikes, etc.)*

What are your concerns, and what would you like us to work on?*

Which services would you like for us to provide?*

Occupational TherapySpeech TherapyPhysical Therapy

When would you like to have services?*

Do you have any animals in the house?*

NoneDog(s)Cat(s)

If you have answered YES to the above question, please acknowledge here that you will keep the animal(s) confined during therapy sessions. *

I acknowledge

In accordance with ARS 11-1014(E), any person with direct knowledge of an animal bite, shall immediately report the incident including the date, time, location of the incident and animal owner to the country enforcement agency.*

I acknowledge

Client's SSN

Client's DDD Assist # (if applicable)

Diagnoses (Please list all applicable)*

Parent/Guardian 1's Name:

First Name Middle Name Last Name

Parent/Guardian 1's Work Number:

Area Code Phone Number

Parent/Guardian 2's Name:

First Name Middle Name Last Name

Parent/Guardian 2's Work Number:

Area Code Phone Number

DDD Case Manager (if applicable)

First Name Last Name

DDD Case Manager's Phone Number:

Area Code Phone Number

Policy Holder's Name

First Name Last Name

Policy Holder's SSN

Policy Holder's Date of Birth

Date

Policy Holder's Employer

Policy ID Number

Policy Group Number

Insurance Phone Number:

Area Code Phone Number

Send Claims to:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Policy Holder's Name

First Name Last Name

Policy Holder's SSN

Policy Holder's Date of Birth

Date

Policy Holder's Employer

Policy ID Number

Policy Group Number

Insurance Phone Number:

Area Code Phone Number

Send Claims to:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Medical Information Release

I hereby authorize the release of any information, including the diagnosis and the records of any treatments or examinations rendered, to my insurance company or companies, or other healthcare agencies. I also authorize the release of medical records or copies of such and request that they be transferred to Therapy Matters, INC. 1334 E. Chandler Blvd. STE 5A01 Phoenix, AZ 85048

Please initial that you have read and understand the Medical Information ReleaseSignature*

Clear

Financial Policy

DDD Only:

Clients authorized for therapy by the Arizona Department of Economic Security, Division of Developmental Disabilities (DDD), are not responsible for payment of charges.

Non-DDD (Insurance and Private Pay)

I understand and agree that I am ultimately responsible and liable for payment of all charges assessed for professional services rendered and will pay any sum due upon demand. I understand that insurance claim forms will be submitted to my insurance company as a matter of convenience. I understand and agree that if it becomes necessary to retain an attorney and/or collection agency for the collection of any outstanding charges, whether or not a lawsuit is filed on my account, I will be responsible for any attorney and/or collection fees and court costs in addition to the outstanding balance.

Cancellation and No-Show Policy

In an effort to be respectful of your busy schedule and our therapists; and secondary to the demand for therapy services, Therapy Matters, INC. employs an attendance policy for all scheduled therapy appointments.

Planned Cancellations

It is the parent’s/caregiver’s responsibility to keep the therapist informed of any changes they need to make in their scheduled therapy visits. We request a 24-hour notice of any cancellations so that adjustments can be made and make up sessions scheduled if possible.
Our Therapist will give a minimum of 48-hour notice for any planned cancellations they need to make (due to planned reasons such as vacation, etc) with regard to your scheduled visits.

Cancellations Due to Illness:

It is important that both the parent/caregiver and therapist be respectful of health concerns. Clients with diarrhea, vomiting, contagious diseases and/or a temperature above 100 degrees should not be seen to ensure the health of the therapist and other clients being treated that the illness could spread to.
Should the client (or another person in the home who will be there during therapy time) wake up with any of these symptoms, please contact your therapist as soon as possible. Your therapist will likewise call as soon as possible should she/he be ill and not be able to render services to the client. The client should be symptom free for 24 hours before resuming therapy.

Failure to call to cancel three or more scheduled appointments will result in the termination of therapy services.

Billing/Cancellations:

If you need to cancel an appointment, we request 24-hour notice. If you cancel within less than 24 hours of your scheduled appointment, you may be charged for 1/2 of the scheduled session. If you do not call to cancel and fail to keep your appointment, you will be charged 1/2 the scheduled session, Insurance will not pay for such "no shows" or late cancellation charges-these charges must be paid by the client. If you have 2 or more cancellations within a 4-week period, or 2 or more no shows, we reserve the right to discontinue services. If your insurance does not cover the billing of this cancellation, you agree to pay any charges or fees to Therapy Matters, INC. directly for these services.

DDD Only:

Clients authorized for therapy by the Arizona Department of Economic Security, Division of Developmental Disabilities (DDD), are not responsible for payment of charges. Time will be billed to DDD for cancellation, using a portion of the hours provided to the client for services.

Please initial that you have read and understand the Financial Policy.*

Clear

Please initial that you have read and understand the Medical Information Release*

Clear

Please initial that you have read and understand the Cancellation PolicyPlease initial that you have read and understand the Financial Policy*

Clear

Assignment of Benefits

I request that payment of authorized insurance benefits be made on my behalf to Therapy Matters, INC.

Please initial that you have read and understand the Assignment of Benefits*

Clear

Out of Network/Insurance Checks

We bill third-party liability (TPL) first if it is available and then we bill DDD.
In some cases, parents may get checks and although it may have a parent/guardian's name on it, because Therapy Matters, Inc. is out-of-network these checks must be forwarded directly to our main office with your signature on the back along with the explanation of benefits (EOB) within 48hrs of receipt.
Prestamped and addressed envelopes may be provided upon request.
By initialing this section, you agree that by not sending these checks to Therapy Matters, Inc. it equates to Medicare fraud which is class 4 misdemeanor and will result in being sent to collections and losing all DDD/State funded services.
Therapy Matters, Inc. will never invoice you for reimbursement that is “out of pocket” if your child has DDD Services. We only will invoice for checks received from you as a direct result of services which Therapy Matters, Inc. provides.
It is your responsibility as the parent/guardian to send these checks to Therapy Matters, Inc. and this does not require and invoice from us.
Therapists are not involved in anything financial. They may not be given checks or EOBs. Those must go to the main office and any questions you have of this nature must be discussed with the main office only at (480) 207-5975.
Therapists are to provide therapy ONLY and all other logistics should be handled directly with the main office.

Please initial that you have read and understand the Out of Network/Insurance Checks*

Clear

I understand and agree to authorize Therapy Matters, INC. and staff to administer assessments and treatments, as deemed necessary:

Signature*

Clear

Date:

DateHour Minutes AM/PM Option

(This HIPAA Form is designated for the patient named above.)

I hereby authorize use or disclosure of protected health information about me as described below.

The following person and/or company may receive disclosure of rotected health information about the above named patient.

Name*

First Name Last Name

Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Parent or Guardian Name*

First Name Last Name

Electronic Signature Consent - By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. Should you wish to sign a paper form of this intake instead, you may do so. By checking here, you are waiving that right. To change this decision, you must notify Therapy Matters, INC. in writing. Until such notice is received, you are consenting to all documents for future services to be electronically signed as well.*

I consentI do not consent. I will print this form and sign it. Once signed, I will submit to Therapy Matters, INC.

Parent or Guardian Signature*

Clear

Date:

MonthDay Year Hour Minutes AM/PM Option

Confidential Client Information

In case of Emergency

DDD Information

Private Insurance Information

State Coverage

HIPAA