2024 New Patient Intake Form Logo
  • Patient Information

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  • Parent/Guardian Information

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  • Emergency Contact

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  • Insurance Information

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  • Patient History

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  • Areas of Concern

  • Consent to Treat

  • Insurance Coverage

    Copays, deductibles, and coinsurance are due at the time of service.  Unless a written payment plan is in place, all outstanding balances are due prior to the next therapy appointment. Mighty Kids Therapy will verify benefits upon initial appointment.  Verification of benefits is not a guarantee of coverage or payment, and all insurance payments are subject medical necessity and eligibility at the time services are rendered.  Knowledge of maximum number of visits, deductible amounts, and out-of-pocket maximums are your responsibility.  It is your responsibility to update Mighty Kids Therapy regarding loss of coverage or any changes to your insurance.  If you are unable to provide Mighty Kids Therapy with your current insurance information prior to your child’s initial appointment, payment will be due in full when your child arrives for the appointment.

    Developmental Delay Coverage

    Many Insurance plans DO NOT have developmental delay coverage. Even though a pediatrician recommends services, many pediatric therapy diagnoses are considered developmental delays and are excluded from therapy coverage.  Please be sure to verify your benefits with your insurance carrier and/or employer to determine whether there is coverage for developmental delay.  It is your responsibility to know your insurance policy coverage and limitations, including any exclusions. Mighty Kids Therapy will gladly provide you with any information that is required to verify benefits with your insurance carrier.  If it is determined that there is no coverage, you can choose to discontinue therapy services or continue with therapy service at the self-pay rate.

    Divorce Decree

    Mighty Kids Therapy is not party to your divorce decree and is not authorized to enforce compliance. Payment is due at the time of service by the accompanying parent. 

    Authorization and Consent for Treatment

    Mighty Kids Therapy will render routine clinical care including evaluations, educational services, and therapy activities/procedures during receipt of service, and carry out orders of the child’s physician, including consultants, associates, and assistants. Mighty Kids Therapy has not made any guarantee or warranty as to the results of any services or treatments given.

    Authorization for Release of Information

    Mighty Kids Therapy will furnish and release medical information to your private insurance carrier, or other third-party payer, as may be required for determination of benefits payable.  Respecting privacy and anonymity, your child’s records may be reviewed for statistical purposes. Mighty Kids Therapy may communicate all aspects of your child’s care to the referring physician, primary care physician, and any other physician requested by parents/guardians.

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  • Photo Release Form

  • During your child’s therapy, Mighty Kids Therapy may photograph and/or videotape your child for the purpose of treatment and education.  These photos or videos will not be released to the public.

    Mighty Kids Therapy may request to photograph your child for the purpose of professional marketing.  In this case, your child’s image may be included on materials such as flyers, brochures, Mighty Kids Therapy website, and/or Mighty Kids Therapy social media platforms (Facebook, Instagram, etc).

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  • Attendance Policies

  • At Mighty Kids Therapy, our goal is to provide the highest quality of care for your child. This is accomplished by consistent attendance and on-time arrival to scheduled appointments. Missed appointments and late arrivals can inhibit your child’s progress and outcomes. Rescheduling missed appointments is crucial to ensuring your child’s success in therapy. As a courtesy to families, we offer recurring appointment times to be reserved according to your child’s plan of care. If you are unable to attend these appointments consistently, you are at risk of forfeiting this option.

  • Please carefully review and acknowledge the following policies:

  • We encourage you to reschedule all missed appointments to maintain progress and to meet your child's recommended plan of care.

    Thank you for working with us to help your child reach their MIGHTY goals!

     

    Acknowledgment

    I have carefully read, understand, and agree to the attendance policy at Mighty Kids Therapy.

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