• Occupational Therapy Initial Intake Form
  •  -
  •  -
  •  -
  •  -
  • Please write the age your child achieved each milestone:

  •  
  • To ensure a smooth course of Occupational Therapy treatment for your child, please review our payment and appointment policies and ask any questions you may have.


    1. Insurance: We participate in some insurance plans and as a courtesy will bill your primary insurance carrier if you provide all necessary information including an up to date insurance card. If you have insurance with a plan we do not participate in, or do not have insurance, payment in full for each visit is required at the time of the visit. Please note that knowing your insurance benefits and limitations is your responsibility. Please contact your insurance company to verify number of visits, co-pay amount, deductible, need for referral or letter of medical necessity, authorization, precertification, exclusions, etc.


    2. Co-payments and deductibles: All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company.


    3. Non-covered services: Please be aware that some, or perhaps all, of the services you receive may not be covered by your insurance carrier. Insurance carriers and their policies differ widely in terms of what diagnoses and procedures they will cover. Please note that any non-covered services are your responsibility.


    4. Claims submission: We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly and we will assist you in providing that information at your request. Payment for services is your responsibility
    whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company, we are not a party to that contract.


    5. Coverage changes: If your insurance changes, please notify us before your visit so that we can make the appropriate changes to help you receive your maximum benefits. In the event that you do not notify our
    office in a timely manner and your insurance is expired, you will be responsible for any unpaid claims.

    CANCELLATIONS, LATE ARRIVALS; CANCELLATION FEES:


    1. Cancellations for any reason other than the client’s illness, must be made with 24 hours notice or a $50.00 cancellation fee will be charged. Insurance cannot be billed for this fee. Advance notice allows us to offer the appointment to another client, as well as notify the OT.


    2. Cancellations for a client’s illness must be made by 9 am the day of their appointment. Any call outs for illness made after 9 am will be charged a cancellation fee. Cancellation for the illness of a parent, spouse, family member or sibling will also incur a cancellation fee.


    3. If you are late to an appointment, we will need to conclude the session at the usual time. If your therapist is running late for any reason, you will be given your full session time. We regret any resulting inconvenience to your personal schedule.


    ATTENDANCE POLICY:
    1. You are asked to maintain attendance that keeps you in good standing with our
    attendance policy. This allows us to maintain a consistent and quality therapy program, and to maximize your child’s progress and to avoid regression of skills.


    2. Clients who miss 2 consecutive sessions, without calling us and do not return our calls regarding the absences, will be removed from our schedule. We will assume that you are terminating therapy for your child. You will, however, be charged the full amount of your final two sessions.

     

    You will be contacted to set up an evaluation. We look forward to hearing from you!

  • Clear
  • Browse Files
    Cancelof
  • Should be Empty: