Minor Client Intake - Partner Sites

Minor Client Intake - Partner Sites
Date: *

Month Day Year
Clinic: *
Services Requested: *

Occupational Therapy Speech Therapy
OT Evaluation in last year? *

Yes No
If yes, please select date of exam:

Month Day Year
Speech Evaluation in last year? *

Yes No
If yes, please select date of exam:

Month Day Year
Contact Information
Parent / Caregiver: *

First Name Last Name
Client Name: *

First Name Last Name
Date of Birth: *

Month Day Year
Age: *
Gender: *
Client Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent / Caregiver Phone Number (1): *
Please enter a valid phone number.
Parent / Caregiver Email (1):
example@example.com
Parent / Caregiver Phone Number (2):
Please enter a valid phone number.
Parent / Caregiver Email (2):
example@example.com
Primary language of parent: *
Interpreter needed? *

Yes No
Primary language of client: *
Medical Information
Allergies / Precautions:
Medical diagnosis:
Date of diagnosis:

Month Day Year
Preferred Method of Contact:

Phone Text Email
Best time to contact you:

Morning Afternoon Evening
Signature: *

Clear
Authorization for Access, Release and Use of Medical and Educational Information

Between A Chance To Grow and Smart Therapy Center.
Client Name: *

First Name Last Name
Date of Birth: *

Month Day Year
Date
The person named above is or has been a client of Smart Therapy Center and/or A Chance To Grow. Smart Therapy Center and A Chance To Grow are required to keep personal information, identifying information, and records confidential. By signing below, clients allow ACTG and Smart Therapy Center to access, send, and/or use medical and educational information between the two clinics to support collaboration of care.

Release:
I hereby authorize ACTG to: *

Request health information from each other Send health information to each other Discuss health information with each other I do not authorize ACTG and Smart Therapy Center to request, send or share my health information at this time.
Date: *

Month Day Year
Date
Scope of information to be released: *

All information regarding assessment, diagnosis, and treatment Other (please specify below)
Other information to be released:
This release will expire one year from the signed date.
Guardian Signature: *

Clear
Date: *

Month Day Year
Date
Authorization for Access, Release and Use of Medical and Educational Information

Between A Chance To Grow and Minnesota Therapy Clinic.
Client Name: *

First Name Last Name
Date of Birth: *

Month Day Year
Date
The person named above is or has been a client of Minnesota Therapy Clinic and/or A Chance To Grow. Minnesota Therapy Clinic and A Chance To Grow are required to keep personal information, identifying information, and records confidential. By signing below, clients allow ACTG and Minnesota Therapy Clinic to access, send, and/or use medical and educational information between the two clinics to support collaboration of care.

Release:
I hereby authorize ACTG to: *

Request health information from each other Send health information to each other Discuss health information with each other I do not authorize ACTG and Minnesota Therapy Clinic to request, send or share my health information at this time.
Date: *

Month Day Year
Date
Scope of information to be released: *

All information regarding assessment, diagnosis, and treatment Other (please specify below)
Other information to be released:
This release will expire one year from the signed date.
Guardian Signature: *

Clear
Date: *

Month Day Year
Date
Authorization for Access, Release and Use of Medical and Educational Information

Between A Chance To Grow and R'Future Wellness & Autism Center.
Client Name: *

First Name Last Name
Date of Birth: *

Month Day Year
Date
The person named above is or has been a client of R'Future Wellness & Autism Center and/or A Chance To Grow. R'Future Wellness & Autism Center and A Chance To Grow are required to keep personal information, identifying information, and records confidential. By signing below, clients allow ACTG and R'Future Wellness & Autism Center to access, send, and/or use medical and educational information between the two clinics to support collaboration of care.

Release:
I hereby authorize ACTG to: *

Request health information from each other Send health information to each other Discuss health information with each other I do not authorize ACTG and R'Future Wellness & Autism Center to request, send or share my health information at this time.
Date: *

Month Day Year
Date
Scope of information to be released: *

All information regarding assessment, diagnosis, and treatment Other (please specify below)
Other information to be released:
This release will expire one year from the signed date.
Guardian Signature: *

Clear
Date: *

Month Day Year
Date
Authorization for Access, Release and Use of Medical and Educational Information

Between A Chance To Grow and ISKA, Inc.
Client Name: *

First Name Last Name
Date of Birth: *

Month Day Year
Date
The person named above is or has been a client of ISKA, Inc. and/or A Chance To Grow. ISKA, Inc. and A Chance To Grow are required to keep personal information, identifying information, and records confidential. By signing below, clients allow ACTG and ISKA, Inc. to access, send, and/or use medical and educational information between the two clinics to support collaboration of care.

Release:
I hereby authorize ACTG to: *

Request health information from each other Send health information to each other Discuss health information with each other I do not authorize ACTG and ISKA, Inc. to request, send or share my health information at this time.
Date: *

Month Day Year
Date
Scope of information to be released: *

All information regarding assessment, diagnosis, and treatment Other (please specify below)
Other information to be released:
This release will expire one year from the signed date.
Guardian Signature: *

Clear
Date: *

Month Day Year
Date
Insurance and Service Authorization
Client Name: *

First Name Last Name
Date of Birth: *

Month Day Year
Date
A Chance To Grow will bill my insurance company for recommended medically necessary services. This includes Occupational Therapy and Speech Therapy. If your insurance company denies these charges, for any reason that is outside of A Chance To Grow, Inc.'s billing responsibilities, you will be responsible for paying for the services.
Please check the box to indicate you've read and understand the following information:

INSURANCE-BASED SERVICES: I want to receive the recommended insurance covered services at A Chance To Grow, Inc. My insurance will be billed for an official decision regarding payment for each individual service and the dates they are provided. Please understand that if your insurance does not pay for any reason that cannot be corrected on our end, you are financially responsible for payment. You may appeal to the insurance company, if your insurance does pay, A Chance To Grow, Inc. will refund any payment (Minus copayments and deductibles).
A Chance To Grow, Inc. will verify your insurance for active coverage, and determine benefits to the best of our ability with the information that your insurance company will share with us. We recommend that the policyholder also call to verify coverage, as they will have access to more information than a provider. If your insurance coverage has a copayment, please be aware that copayments are due at the time of service. You are required to make monthly payments on any balance that you accrue. We reserve the right to discharge from services for failing to meet financial obligations.
Primary Insurance Company:
Name of Policy Holder:
Social Security Number of Policy Holder:
Date of Birth (Policy holder):
Policy Number:
Employer Name:
Employer Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
By signing this form you understand that this gives A Chance To Grow, Inc. the right to verify and bill your insurance company. This form also acknowledges that you are aware that if for any reason services are not covered or they are denied for a reason that we cannot appeal you are financially responsible for the charges.
Guardian Signature:

Clear
Date:

Month Day Year
Date
Authorization for Access, Release and Use of Medical Information
Date:

Month Day Year
Date
Client Name:

First Name Last Name
Date of Birth:

Month Day Year
Date
The person named above is or has been a client of A Chance To Grow, Inc. ACTG is required to keep personal information, identifying information, and records confidential. By signing below, clients allow ACTG to access, send, and/or use information from certain individuals or agencies named.
I hereby authorize ACTG to:

Request health information Send health information to Discuss health information with (provide Clinic/Primary Physician details below) I do not authorize ACTG to request, send or share my health information at this time.
Clinic/Primary Physician:
Clinic Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Clinic Phone Number:
Please enter a valid phone number.
Clinic Fax Number:
Please enter a valid phone number.
Scope of information to be release:

All information regarding assessment, diagnosis, and treatment Other (please specify below)
Other information to be released:
If applicable and pertains to direct treatment:
The following information requires specific authorization due to additional release protection. To authorize release or discussion of the following type of information with your provider, you must initial and date each item. If an item is not initialized and dated, the information, if such exists, cannot be released or discussed.
Initial   Date Alcohol Use / Abuse Treatment
Initial   Date Drug Use / Abuse Treatment
Initial   Date Mental Health Treatment
Initial   Date HIV Status or Treatment
Please initial the following:
Initial   I understand that this authorization is effective for the above requested and authorized health care information only.
Initial   I understand that I have the right to inspect the information I am authorizing to be re-released. This and other specific rights regarding the handling of your health information are outline in our privacy practices document.
Initial   I understand I do not have to allow A Chance To Grow, Inc. to share my information and that signing a release form is completely voluntary. My refusal to sign this authorization will not affect my ability to obtain treatment except to the extent that the information being requested may assist ACTG in determining appropriate treatment.
Initial   I understand that if I would like A Chance To Grow, Inc. to release information in the future, I will need to sign another written, time-limited release. This release is limited to the information contained in this document.
Initial I understand that my information may be shared in person, by phone, fax, mail or e-mail. I understand that email is not confidential and can be intercepted and read by other people. Releasing information about me could give another agency or person information about my location and would confirm that I have been receiving services from ACTG.
Initial   I understand that I may withdraw my consent to this release at any time in writing. ACTG may not be able to control what happens to my information once it has been released to the the above person or agency, and that the agency or person getting my information may be required by law or practice to share with others.
Initial   I understand that records created by and available from other providers, hospitals, or other care facilities must be obtained from those other providers or facilities.
Authorization:
Name:

First Name Last Name
Guardian Signature:

Clear
Date:

Month Day Year
Date
Authorization For Access, Release and Use of Educational Information
Date:

Month Day Year
Date
Client Name:

First Name Last Name
Date of Birth:

Month Day Year
Date
The person named above is or has been a client of A Chance To Grow, Inc. ACTG is required to keep personal information, identifying information, and records confidential. By signing below, clients allow ACTG to access, send, and/or use information from certain individuals or agencies named.
I hereby authorize ACTG to:

Request health information from Send health information to Discuss health information with (provide school details below) I do no authorize A Chance To Grow, Inc. to request, send, or share my educational information at this time.
School:
Case Manager and/or Teacher:
School Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
School Phone Number:
Please enter a valid phone number.
School Fax Number:
Please enter a valid phone number.
Scope of information to be released:

All information regarding assessment, diagnosis and treatment Other (please specify below)
Other information to be released:
Please initial the following:
Initial   I understand that this authorization is effective for the above requested and authorized educational information only.
Initial   I understand that I have the right to inspect the information I am authorizing to be re-released. This and other specific rights regarding the handling of your health information are outline in our privacy practices document.
Initial   I understand I do not have to allow A Chance To Grow, Inc. to share my information and that signing a release form is completely voluntary. My refusal to sign this authorization will not affect my ability to obtain treatment except to the extent that the information being requested may assist ACTG in determining appropriate treatment.
Initial   I understand that if I would like A Chance To Grow, Inc. to release information in the future, I will need to sign another written, time-limited release. This release is limited to the information contained in this document.
Initial I understand that my information may be shared in person, by phone, fax, mail or e-mail. I understand that email is not confidential and can be intercepted and read by other people. Releasing information about me could give another agency or person information about my location and would confirm that I have been receiving services from ACTG.
Initial   I understand that I may withdraw my consent to this release at any time in writing. ACTG may not be able to control what happens to my information once it has been released to the the above person or agency, and that the agency or person getting my information may be required by law or practice to share with others.
Initial   I understand that records created by and available from other providers, hospitals, or other care facilities must be obtained from those other providers or facilities.
Authorization:
Name:

First Name Last Name
Guardian Signature:

Clear
Date:

Month Day Year
Date
Should be Empty:

Minor Client Intake - Partner Sites

Contact Information

Medical Information

Authorization for Access, Release and Use of Medical and Educational Information

Authorization for Access, Release and Use of Medical and Educational Information

Authorization for Access, Release and Use of Medical and Educational Information

Authorization for Access, Release and Use of Medical and Educational Information

Insurance and Service Authorization

Authorization for Access, Release and Use of Medical Information

Authorization For Access, Release and Use of Educational Information