The Responsible Party is the person signing the intake paperwork. Typically this is either the Client or the Parent/Guardian of a Client.
I acknowledge that I have received a Medicaid Member Handbook and Provider Directory (either in the mail or from my provider *link above). I understand that the purpose of this book is to ensure I have information about my benefits, rights andresponsibilities. The handbook also provides information on how to receive covered services, access to emergency services, transportation and how to choose a provider. The handbook also addresses procedures for filing grievancesand appeals.I also understand that if I have been treated unfairly or discriminated against for any reason, I may file a complaint by contacting Optum Health at 1-877-370-8593
INSTRUCTIONS: Looking back over the last week, including today, helpus understand how you have been feeling. Read each item carefully and selectthe category which best describes your current situation. For this questionnaire, workis defined as employment, school, housework, volunteer work, and so forth.
DIRECTIONS: Read each statement carefully. Decide how true this statement is during the past 7 days for your child. Select the choice that most acurately describes the past week.
Please complete Primary Insurance Information (& Secondary if you have this). If not using insurance (example, Self-pay, CVR, Voc Rehab etc), note this in Primary Insurance Box
At Aspen Ridge Counseling, we feel it is important to work with your Primary Care Physician to provide the best care possible. Please complete as much of this information as you are able to allow your Therapist to coordinate with your Primary Care Physician.
By signing and checking above boxes, I agree that I've read the Informed Consent, HIPAA guidelines and LC/NS policy. I also am advising that all information completed in this packet is accurate and will update Aspen Ridge Counseling with any changes that may impact services.