Patient Intake Forms

Patient Intake Form
Please Note:

This form will take approximately 5 - 10 minutes to complete.

Several consents and policies within this paperwork require your E-Signature.

Please complete all of this information at least 48 hours prior to your child's appointment. This information is required to start your child in therapy and to bill your insurance. All information is confidential.
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Payment Information
I will be paying for my child's therapy with...*
Please select only ONE of the following options
Insurance or Self-Pay Options

I want FUNctionabilities to deal directly with my insurance. I will assign my benefits to you by completing the "Assignment of Benefits Form". Fees may apply if not filled out completely and correctlyI want a 15% discount by paying the entire bill at the time of service. I will seek reimbursement on my ownI want a 15% discount for paying the entire bill at the time of serviceI want a 15% discount for paying the entire bill at the time of serviceI want to apply for "Financial Hardship" to get on a payment plan
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Parent Permission

(Initial in the boxes below)
1. AUTHORIZATION OF SERVICES: I give my consent for my child to receive services provided by FUNctionabilities in the clinic, my home, and / or in the community.*
2. RELEASE OF INFORMATION: I authorize the exchange of information between FUNctionabilities, physician's offices, therapy providers, insurances, and school records as they apply to the provision of therapies.*
3. PHOTO CONSENT: I hereby authorize FUNctionabilities to photograph / videotape my child for the purpose of:
a. Documenting my child's therapy *
b. Publications or educational programs*

YESNO
c. Promotional ads for FUNctionabilities.*

YESNO
4. OBSERVATION CONSENT: I understand that FUNctionabilities is a teaching facility and I hereby give permission for students to participate in and observe my child's therapy.*
5. PARENT PROXY: I understand that if another person accompanies my child to therapy I am authorizing information to be released to that person.*
Parent Signature*

Clear
Today's Date*

MonthDayYear
Date
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Referral Information
How did you hear about us? Check one*

BrochureWebsiteAdvertisementSocial MediaInsurance / DirectoryFamily / FriendOther Healthcare ProfessionalOther
Referred by:
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Policies & Procedures

(Initial in the boxes below)
Late Policy: We have a strict late policy because we try very hard to run on time. If you arrive after the appointment time you will be charged a $25 late appointment fee. Insurances only reimburse us for face-to-face time with your child so if you are late, both your child and our clinic lose out. We reserve the right if you are late by 10 minutes or more to require you to reschedule or wait for the next opening and charge a cancellation fee. There are no guarantees since cancellations are unpredictable. We do not allow appointments to overlap because this undeservedly compromises the care of another patient. To avoid any fees, please be early for your child's appointment.*
48-Hour Advance Notice Policy: If you wish to change or cancel an appointment, we require a minimum 48-hour advance notice. Anything less will result in a $40 cancellation fee charged to your account. Whether your child attends or not, it costs us money to make appointments available to you (for staff wages, rent, etc.). We do not make money with this charge; the fee is to act as a deterrent from making last minute changes. Advance notice allows another child in need time to reserve an appointment in place of your child. Please be courteous and responsible. Thank you.*
No-Shows: No-shows are bad. If you fail to show up for an appointment without notice, all future appointments may be cancelled, and a $50 fee will be assessed to your account. If there are 2 no shows within 90 days, we may opt to no longer provide services to your child allowing us to provide services to another child who needs therapy. We reserve the right to discontinue services under any circumstance as we may elect at our sole discretion.*
Child-Centered Policy: We believe firmly in a child-centered model of treatment and contribute our amazing results to this focus. This model allows us to focus on the child and grants you to wait in the lobby and take a break from the difficult job you have as a parent. *
Minors and Parents: If a patient is a minor (under 18 years of age), the parent or legal guardian is responsible for all charges and decisions made by the minor. We do not assume any liability for the minor while on the premises or not. It is the responsibility of the parent or guardian to supervise the minor before and after treatments. You should be available during the session in case you are needed. Should any of your children be left unattended before, during, or after a session you will incur at least a $15 fee since this requires a member of our team to sit with your child at the expense of leaving their regular duties.*
Treatment Time: Please be cognizant of the time you spend with our therapists. If you require more time, please set up an appointment so we don’t take away time set aside for your child or someone else’s child. Consultation can include preparation for IEPs, 504s, or other in-depth questions. Remember therapy sessions are 45 minutes and 30 minutes as laid out in the Welcome Letter. When you respect our time by setting up an appointment to further discuss your child’s needs, we will give you a 50% discount off our consultation fee.*
Consultation Policy: We want to devote every moment possible with your child. While we believe that your involvement and education is critical to your child’s success, insurances do not pay for us to consult with you. We set aside a few minutes each session to discuss your child’s care with you and we will continue to provide homework to facilitate your child’s care. Our parent consultation fee starts at $50 for 15 minutes.*
Results: The purpose of occupational and speech therapy is to maximize your child’s own learning potential through natural means and to promote their ability to perform daily play, leisure, social, and sports activities through increased self-regulation, communication, motor planning, strength, and movement strategies. It is not possible to predict the results or outcomes of treatment. Typically, benefits are realized gradually over time. Each case is unique and FUNctionabilities makes no representations or warranties regarding results of therapy provided.*
Informed Consent: By signing our authorization for treatment (herein), the parent or guardian represents and warrants that they are authorized to sign and hereby gives our facility permission for the evaluation and treatment of the child. It is your right to accept or refuse any treatment offered. There are no guarantees made as to the results that may be obtained from our treatment(s). If you have any questions about your child’s care, be sure to ask a therapist. It is up to the parent/guardian to inform the therapist about any health problems or allergies the child may have. The parent/ guardian must also tell the therapist about drugs or medications being taken and any medical conditions and/or previous or planned surgeries. Please discuss any questions or problems with the therapist before signing this statement of understanding and consent for care. Any legal fees incurred concerning your child's treatment or account may be passed on to you where applicable.*
Important Notice from the Federal Government: “It is unlawful to routinely avoid paying your copay, deductible or coinsurance payments… even if your doctor allows it. Unless you complete a “Financial Hardship” form and qualify for financial assistance under Federal Standards, you may NOT routinely evade paying your responsibility portions for medical care as outlined in your insurance plan, even if your doctor allows it. You may both be charged with breaking the law. This includes services deemed as “professional courtesy” and TWIP’s – take what insurance pays”. Failure to comply may place you in violation one or more of the following laws: Federal False Claims Act, Federal Anti-Kickback Statute, Federal Insurance Fraud Laws, State Insurance Fraud Laws. Failure to comply may result in civil money penalties (CMP) in accordance with the new provision section 1128 A (a)(5) of the Health Insurance Portability and Accountability Act of 1996 (section 231(h) of HIPAA). Exceptional cases do apply. Please see contact info for more information: Office of Inspector General, Department of Health and Human Services. Contact by phone: 202-619-1343, by fax 202-260-8512, by email: paffairs@oig.hhs.gov, by mail: Office of Inspector General, Office of Public Affairs, Dept. of Health and Human Services, Room 5541 Cohen Building 333 Independence Ave, S.W., Washington, D.C. 20201, Joel Schaer, Office of Counsel to the Inspector General, 202-619-0089.”*
I have read and agree to all of the policies listed above (Please sign, do not merely initial).*

Clear
We look forward to building a relationship with you that will last a lifetime!
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Payment Agreement
Thank you for choosing FUNctionabilities for your Pediatric Therapy needs. This financial agreement describes both patient and insurance responsibility for services rendered. Please read this agreement, ask us any questions you may have, and sign in the space provided.
Patient Responsibility & Payments: We will collect your portion upfront. When you arrive at each appointment, please have cash or a credit card available so you can pay your portion of the services we provide your child. If you do not pay at the time of service a $10 fee will be assessed to the account. You are ultimately responsible if your insurance denies a claim for any reason. Our office will not be involved with separation or divorce disputes. Therefore, the parent who consents to the treatment of a minor child is responsible for payment of services rendered. If you do not have insurance or you choose to deal with your insurance company directly, payment in full will be due at the time of service. A 15% discount will be offered for payments made in full at the time of service. Upon request we can provide you with a detailed invoice of the services rendered. The amount of your bill is expected to be paid in full upon receiving the statement, unless payment arrangements have been made with our office staff. Anything over 30 days is considered past due.*
Costs: There are extra charges for evaluations, progress reports, re-assessments, and discharges. These extensive reports are NOT included in the discounted package prices nor are they always covered by insurance. All charges for these services are to be paid at the time of service. If you do not pay your portion at the time of service, we will charge an administration fee of $10. If we incur chargeback fees, we will pass them on to your account at $25 per occurrence.*
Insurance: Your insurance coverage is a contract between you and the insurance company; we are not a party to that contract. We must emphasize that as medical care providers, our relationship is with you, not your insurance company. It is your responsibility to know your benefits and insurance coverage for therapy services, if any, including any referrals, authorizations, maximums, or exclusions. All patients are responsible for all charges whether paid by insurance or not for any reason including but not limited to medical necessity or protocol denials. As a courtesy we will submit your claims to your primary and secondary insurance companies, however we do expect payment for all services within 30 days. It may become necessary for you to pay your account in full if your insurance fails to do so within 30 days. If we are given incorrect or incomplete insurance information you will be billed and payment will be expected within 30 days. *
Non-Payment: Any unpaid balances that have not been paid within 15 days of the date of the invoice shall incur a 10% late fee. Any open balance will be charged to the credit card on file. Failure to pay will result in your account being referred to a collection agency, which may affect your credit. A collections fee not to exceed 40% of the unpaid balance as allowed by Utah Code Annotated, sec. 12-1-11, will be added to your account. You agree to pay all legal fees associated with the collection process, with or without suit, including any collection costs, reasonable attorney's fees, and other fees. If a balance is owed past 120 days we may start a care credit account on your behalf for the balance due. *
Cash Packages: Our cash packages are to help you if you have no out-of-network benefits, large deductibles, or poor coverage for therapy. We do NOT bill insurance if you utilize our cash packages. The parent listed below agrees to this payment method for the patient’s outstanding account balance in place of insurance. Should the parent deviate from the prescribed payment plan at any time (including but not limited to: missed payments, late payments, declined payments, or payments not made in full) FUNctionabilities reserves the right to charge interest, penalties, terminate services, or consider delinquency at any time.*
You understand that in the event any of your payments are late, FUNctionabilities will add a late fee to your account in the amount of 10%. Finance charges will accrue from the original charge date. This fee is enforced to prevent frequent increases in the fees for medical services. Remember, if you receive a cash discount, we will NOT bill your insurance. Progress reports, re-assessments, and discharges are NOT included in the discount package pricing. *
I have received this financial policy and understand that regardless of any insurance coverage I may have, I am responsible for payment of my account. I understand that delinquent accounts will be referred to a collection agency. If it becomes necessary to send my account to a collection service, I agree to reimburse FUNctionabilities the fees of any collection agency, which may be based on a percentage of the debt as laid out above, and all costs, and expenses, including reasonable attorneys’ fees, incurred in such collection efforts. The terms and conditions contained within this agreement shall be governed by the laws of the State of Utah and shall be contrued and interpreted in accordance with those laws. Any action or proceeding brought by either party which is based upon or derived from, or in any way related to this agreement, shall be brought in a court of competent jurisdiction within the state of Utah. The parties hereto consent to their personal jurisdiction of said court.
Today's Date*

MonthDayYear
Date
Parent / Guardian Name*

First NameLast Name
Signature*

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(You must review your information prior to submitting)
Should be Empty:

Patient Intake Form

Personal Information

Payment Information

Parent Permission

Referral Information

Policies & Procedures

Assignment of Benefits

Payment Agreement