ITTS for Children Admissions Packet

To avoid misunderstandings regarding MEDICAL INSURANCE, we wish our clients to know that all professional services rendered are charged directly to the CLIENT and that the clients are personally responsible for payments of fees. We are out-of-network providers here at ITTS For Children for ALL insurance companies, which means that WE DO NOT FILE INSURANCE CLAIMS. We will provide you with a bill/receipt at the end of your evaluation/session which you can file with your insurance company.

We will prepare reports to help you obtain your benefits from your insurance companies, as they are requested. We have learned through experience that your insurance company is apt to require a DIAGNOSIS CODE (ICD-10-CM#) on the monthly billing statements. Since we are not legally allowed to diagnose children here, we will need a COPY OF A PRESCRIPTION from your PHYSICIAN or a LETTER OF MEDICAL NECESSITY indicating the medical diagnosis to be able to place this information on your billing.

We do not render our services on the basis that insurance companies will pay all our fees. Each fee is individual for the individual client. If, after 45 days from the date of billing, your insurance company has not paid your bill, it is DUE AND PAYABLE IN FULL BY YOU. If you are unable to pay your account in full, please make arrangements with our office/billing manager for punctual monthly payments. You can reach the office/billing manager at the telephone number below or by email at: billing@ittsforchildren.com

I hereby grant Individual and Team Therapy Services for Children (ITTS for Children) PERMISSION to take still photographs and video tape recordings of:

(myself, my child) during the evaluation and/or treatment sessions at this facility. It is my understanding that Dr. Milagros J. Cordero, OTR/L, staff consultants, and employees of Individual and Team Therapy Services for Children will not willfully release photographs and/or video tapes to an outside source without first obtaining parent/guardian written consent.

Select to indicate no permission granted.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

A biological childAn adopted child, with medical history availableAn adopted child with no previous history availableOther

	Smoked Regularly	Smoked Occasionally	Had two or more drinks daily	Used illegal drugs regularly	N/A
Mother
Father
Other Parent

NursedBottle-fedBoth

Please complete the following information as best you can, by providing us with the AGE the child was when the following was accomplished:

PEDIATRIC ADMISSION PACKET

ITTS For Children

INSURANCE INFORMATION AND PAYMENT AGREEMENT

AUDIO/VISUAL RELEASE

COMMUNICATION RELEASE

ADMISSION FORM

General Information on the Child

Parent/Legal Guardian Information

Medical Background

Developmental History