Georgia Patient Form

Georgia Patient Form
Caregiver Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Select ALL insurance plans that cover the child

Advent HealthAETNABlue Cross Blue ShieldCaresourceCIGNAPeach StateTricareUHC/Optum
Alternative Number
How did you hear about us?

Friend or FamilyGoogleFacebookSchool or Day Care CenterOther
Type of Insurance*

MedicaidPrivate
Name of Insurance
Name of Private Insurance Company

Advent HealthAETNABlue Cross Blue ShieldCaresourceCIGNAPeach StateTricareUHC/OptumOther
Insurance ID
Patient's Name*

First NameMiddle NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Does the family speaks fluent English or primarily Spanish?*

Fluent EnglishFluent Spanish
Patient's Sex*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Check all the behavioral concerns that apply to your child:*

ElopementPhysical AggressionTantrumTask RefusalSelf Injurious BehaviorProperty DestructionSpittingMouthing ObjectsDisrobingVerbal AggressionOther
Diagnosis Code
The patient is currently attending:*

SchoolDay CareHome SchoolOther
Name of the Patient School or Day Care Center
Doctor's Name and Practice
Doctors' Office Phone Number
Doctor's Mailing Address
Delivery Method

MailPhoneFaxEmail
Choose "I Authorize ALL" or select individually

I authorize ALL Health information to be disclosedIndividual Education Plan (IEP)Psych Educ. AssessmentReport Cards/TranscriptsBehavioral ReportSpecial ReportPsychological EvaluationMedication Management VisitsSpeech/Language EvaluationHearing ScreeningMedical History and Immunization RecordNeurology ReportPsychiatric EvaluationProgress NotesClient Information SheetIndividualized TreatmentTreatment Plan ReviewsPsychosocial EvaluationBehavioral ProgramDischarge SummaryProgress Summary
Current Status

OnboardingInitial RequestedReady to be AssignedActiveInactiveDischargedX-ROn-HoldPendedOut of Network
Expiration

One YearTwo yearsType a Date: mm/dd/year
Purpose of the Release of Information

At the request of the IndividualAssessmentTreatment
Coordination

Disability DeterminationTo obtain information for Brief Behavioral Health Status ExamOther - Please Specify
Case Manager
Is there a case manager or other support person assisting you with service coordination?*

YesNo
Case Manager Name

First NameLast Name
Case Manager Phone Number
Please enter a valid phone number.
Do you give Full Spectrum ABA permission to discuss your child's needs and services with the person named above?*

YesNo
1) I understand that Full Spectrum Behavior Analysis, LLC cannot guarantee that the Recipient will not re-disclose my health information to a third party. The Recipient may not be subject to federal laws governing privacy of health information. 2) I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect my ability to obtain treatment from Full Spectrum Behavior Analysis, LLC. 3) I understand that I may revoke this Authorization in writing at any time, however, l cannot revoke authorization for action that has already been taken. I further understand that I must provide any notice of revocation in writing to the Business Office at the address listed above.
Copy of Insurance Card - FRONT and BACK

Cancelof
Physician’s referral (Script)

Cancelof
Comprehensive Diagnostic Report

Cancelof
Please E-Sign and Click Submit*

Clear

Georgia Patient Form

Case Manager