Client Name: First Name* Last Name* Client DOB: Client DOB* Parent Name: First Name* Last Name* Parent DOB: Parent DOB* Parent SSN: Social Security # Phone Number: Area Code* Phone Number* Address: Street Address* Apt # City* State* Zip* Email: Email*
Physician Name/Practice: Name* Phone Number: Area Code Phone Number Fax Number: Fax Number Do you have Medicaid? Yes/No* Medicaid Number: Medicaid Number (Type N/A If Not Applicable)* Do you have private insurance? Yes/No* Private Insurance Company Name: Insurance Co (Type N/A If Not Applicable)* Insurance Phone Number: Area Code* Phone Number* Policy ID : Policy ID Number (Type N/A If Not Applicable)* Group : Group Number (Type N/A If Not Applicable)* Policy Holder Name: Policy Holder Name* Policy Holder DOB: Policy Holder DOB (Type N/A If Not Applicable)* Is the policy holders address the same as above? Yes/No* If no, what address? Street Address* Address Line 2* City* State* Zip*
Referral Source: Referral Source What day/time works for you on a consistent basis?Day(s): Day(s)* Time(s): Time(s)*What locations work best for you? Home Daycare Clinic Virtual (Speech Only) SchoolName of Daycare/School: Daycare/School Name Reason(s) for seeking therapy? Reason(s) Additional Information (Previous Services, Diagnoses, etc): Additional Info For questions, Please call (704)846-0262
Early Bird Consent Forms
Client Name: Client Name * Client DOB: Client DOB*Name Of Person Filling Out Form: First Name* Last Name* Relationship to Child: Relationship*
I give my voluntary consent for Early Bird Developmental Services to use and disclose health information regarding Blank* to carry out treatment, payment and health care operations. In addition to sharing health information with my insurance company/Medicaid if requested and acquiring physician orders, I authorize Early Bird Developmental Services to exchange health information with the following agencies or person(s): Blank* (list out any agencies with whom we can exchange information such as your pediatrician, school, etc.)
Consent for Treatment, Payment, and Operations
By signing this form, I am consenting to Early Bird Developmental Services' use of and disclosure of my child's protected health information for treatment, payment, and health care operations. I understand that I do not have to consent to the use or disclosure of my child's protected health information for treatment, payment, and health care operations, but if I do not consent, Early Bird Developmental Services may refuse to provide me health care services. I understand that I can request more information at any time about how Early Bird Developmental Services uses or discloses protected health information to carry out treatment, payment, and health care operations. I understand that I can revoke this consent at any time. This consent is effective until the above-named client is discharged by Early Bird.
I fully understand this document and give my consent. Signature: Signature (Relationship to Client) Relationship* Today's Date: mm/dd/yyyy*
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This is a summary. For the full text of this notice visit www.earlybirdonline.com. For more information or assistance, or to request a printed copy of the full text this notice, contact Robert Kornfeld, Director of Operations, 704-9995-2929 or email@example.com
You have the right to:
You may permit - or deny us permission - to use and share your information in certain ways. Without express written permission WE WILL NOT:
Our Uses and Disclosures
We may use and share your information as we:
I acknowledge by signing below that I have received and read/had explained to me Early Bird Developmental Services' Notice of Privacy Practices Signature: Signature* (Relationship to Client): Relationship* Today's Date: mm/dd/yyyy*
Consent for In-Person Services during Pandemic
This document contains important information about our decision (yours and mine) to resume in-person services during the COVID-19 pandemic. We will return to teletherapy services if lockdown orders are again imposed by local, state or federal authorities, if other health concerns arise, or at any time you or I feel it is safer to do so.
By Signing below, I acknowledge that there are risks associated with in-person services during a pandemic.
Our responsibilities to minimize exposure
To begin or resume in-person services, I agree to take certain precautions which will keep everyone (you, me, our families, and other patients) safer from exposure to the virus that causes COVID-19. If we do not adhere to these safeguards, it may necessitate a return to teletherapy services.
This agreement supplements the original Consent for Treatment, Payment, and Operations that I signed at the start of our work together. Your signature below indicates that you agree to the above conditions.
Caregiver Signature: Signature* Printed Name: Name* Today's Date: mm/dd/yyyy*
Tele-Health Informed Consent Form
Signature: Signature* (Relationship to Child): Relationship* Today's Date: mm/dd/yyyy*