• PEDIATRIC ADMISSION PACKET

  • ITTS For Children

    Individual and Team Therapy Services

  • INSURANCE INFORMATION AND PAYMENT AGREEMENT

  • 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 ask that each family pay IN FULL AT THE TIME OF SERVICE. 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

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • AUDIO/VISUAL RELEASE

  • 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.

  • Permission to photograph/video :
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • COMMUNICATION RELEASE

  • I hereby grant ITTS for Children permission to contact the individuals/agencies listed below. (Ex. physician, psychologist, teacher)
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • ADMISSION FORM

  • General Information on the Child

  • Child's DOB*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Child's Sex*
  • Format: (000) 000-0000.
  • Other therapy/educational services being received or that have been received:*

  • Parent/Legal Guardian Information

  • Parent/Guardian 1 Information:*
  • Parent/Guardian 2 Infomation:*
  • Other individuals living in- or who have lived in- the home?*

  • Medical Background

  • This child is*
  • While pregnant, did the mother smoke, drink, or use illegal drugs regularly?:
  • While the mother was pregnant, did the other parent smoke, drink, or use illegal drugs regularly?
  • Select any of the following that are true. While the mother was pregnant, the parents:*
    Rows

  • Developmental History

  • Complications with development included*
  • Child was nursed, bottle fed, or both?*

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

  • List serious illnesses/hospitalizations and dates:
  • List any medications your child is currently taking:
  • List any medications your child has taken in the past:
  • Should be Empty: