ITTS Family Adult Admission Packet

ADULT ADMISSION PACKET
ITTS FAMILY

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 Codero & Associates/ITTS Family 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-9-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
Client Name*

First NameLast Name
Client Signature*

Clear
Date*

MonthDayYear

AUDIO/VISUAL RELEASE
I hereby grant PERMISSION to Cordero & Associates (DBA ITTS FAMILY) to take still photographs and video tape recordings of myself, First Name Last Name, 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 will not willfully release photographs and/or video tapes to an outside source without first obtaining my written consent.
Permission to photograph/video GRANTED by: (Signature of Client or Legal Representative)

Clear
Date

MonthDayYear
OR
Permission to photograph/video DENIED by: (Signature of Client or Legal Representative)

Clear
Date

MonthDayYear

COMMUNICATION RELEASE
I hereby grant ITTS Family permission to contact the individuals/agencies listed below on my behalf.
I do not grant permission for ITTS to communicate with any individual/agency on my behalf.

Select to indication no permission granted.
Client Name*

First NameLast Name
Client Signature*

Clear
Date*

MonthDayYear

GENERAL INFORMATION
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

Female (including transgender)Male (including transgender)Non-BinaryIntersexPrefer not to answerOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Preferred Phone*
Email address (for scheduling/contact purposes only)*
example@example.com
Referring Physician
Diagnosis Code
Other therapy services being received or that have been received:
Please list any chronic medical conditions:
Please list any medications, vitamins or supplements the client is currently taking:
List any serious illnesses or hospitalizations and dates:
Reason(s) for seeking Occupational Therapy:*
When did your difficulties begin?*
Please describe difficulties:*
Who was the first person to notice these difficulties?*
Do you work? If so, what is your work schedule like?
What type of activities do you enjoy?*
What are your interests or hobbies?
Describe a typical day:*
What are your strengths?*
Please list areas where you would like to see improvements within the next three months:*
Please list areas where you would like to see improvements within the next year:*
Should be Empty:

ADULT ADMISSION PACKET

ITTS FAMILY

INSURANCE INFORMATION AND PAYMENT AGREEMENT

AUDIO/VISUAL RELEASE

COMMUNICATION RELEASE

GENERAL INFORMATION