South Carolina Patient Form

Caregiver Name*

First NameLast Name

Email*

example@example.com

How did you hear about us?*

Phone Number*

Format: (000) 000-0000.

Alternative Number

Format: (000) 000-0000.

Type of Insurance*

MedicaidPrivate

Select ALL insurance plans that cover the child*

Name of the Full Spectrum ABA provider that refereed you:

Name of Insurance

Name of Private Insurance Company

Insurance ID

Insurance Subscriber Name (Policyholder)

First NameLast Name

Date of Birth of Insurance Subscriber (Policyholder)

Date

Patient's Name*

First NameMiddle NameLast Name

Patient's Date of Birth*

Date

Patient's Sex*

MaleFemale

Select your County*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County

Check all the behavioral concerns that apply to your child:*

Does the family speaks fluent English or primarily Spanish?*

Fluent EnglishFluent SpanishOther

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*

Format: (000) 000-0000.

Doctor's Mailing Address

Delivery Method*

MailPhoneFaxEmail

Choose "I Authorize ALL" or select individually*

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

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.Format: (000) 000-0000.

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.

South Carolina Patient Form

Case Manager

OPTIONAL