Initial Inquiry Packet

Initial Inquiry Packet
This document and its attachments contain privileged and confidential information and/or protected health information (PHI) intended solely for the use of Aspen Behavioral Consulting and the recipients(s) listed within. If you are not the recipient, legal guardian of the recipient, the employee or agent responsible for, you are hereby notified that any review, dissemination, distribution, printing or copying of this document is strictly prohibited under Health Insurance Portability and Accountability Act (HIPAA).

If you have received this document in error, please notify Aspen Behavioral Consulting immediately at 480-744-5286 and return this document to the address listed on this document or shred the document in its entirety.

At Aspen Behavioral Consulting, our mission is to produce lasting outcomes to those we partner with through the practice of applied behavior analysis. We want to thank you for partnering with us and for providing us with the opportunity to help navigate behavior analytic services while also working together to find the best fit for services for your family.

Throughout all phases of treatment, including the referral, intake and registration process at Aspen Behavioral Consulting, our intent is to gain a comprehensive understanding of each individual patient’s baseline and present levels of performance, including their strengths and needs. In order to do so, we rely heavily on input from parent(s)/guardian(s), file reviews, and direct and indirect assessments. The information obtained within these processes will provide a basis for treatment recommendations moving forward. If at any time within the process you have questions or concerns or would like clarification, please do not hesitate to reach out for support. You can reach Kristine Mooney, the Chief Clinical Officer at Aspen Behavioral Consulting directly at (480) 744-5286 or via email at kristine@aspenbehavioral.com.

To participate in a referral to Aspen Behavioral Consulting for Applied Behavior Analytic (ABA) services, please review and complete the documents included in this packet. A checklist has been provided below to assist in ensuring all requested documents are reviewed, completed and submitted.
Referral Packet Checklist
A finalized packet, along with a psychological assessment and/or diagnostic report, will be required prior to the intake being initiated.

Patient Information
Patient's Legal Name:*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Failure to disclose primary or secondary insurance (where applicable) could result in additional financial responsibility and/or the termination of services at Aspen Behavioral Consulting.
Primary Coverage - Policy Holder's Information
Policy Holder:*

First NameLast Name
Date of Birth:

MonthDayYear
Date
Phone Number:*
Please enter a valid phone number.
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Insurance Carrier:*
Insurance Phone Number:*
Please enter a valid phone number.
Insurance Billing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contract Number/ID Number:*
Group Number:*
Employer's Name:*
Is there a Secondary Coverage? (Please include AHCCCS/DDD)*

YesNo
Policy Holder:*
Date: of Birth:*

MonthDayYear
Date
Phone Number:*
Please enter a valid phone number.
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Insurance Carrier:*
Insurance Phone Number:*
Please enter a valid phone number.
Insurance Billing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contract Number/ID Number:*
Group Number:*
Employer's Name:*
Parent/Guardian Consent to Contact Insurance
Based on the information I have provided and confirmed by me personally, as the legal guardian of the patient listed above:*

I consent to Aspen Behavioral Consulting contacting my insurance carrier (Named above) to verify coverage for Applied Behavior Analytic (ABA) services.I do not consent to Aspen Behavioral Consulting contacting my insurance carrier (named above) to verify coverage
Name of Parent/Guardian:*

First NameLast Name
Date:*

MonthDayYear
Date
Signature*

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Please submit a copy of the front and back of your insurance card(s) for future reference.

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Patient Information
Patient's Legal Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Under the Health Insurance Portability and Accountability Act (HIPAA) of 1996, Aspen Behavioral Consulting is required by law to maintain the privacy of protected health information (PHI) for each patient and/or potential patient. This notice provides information regarding how Aspen Behavioral Consulting may use and disclose protected health information (PHI) about a patient and the patient’s rights with regard to the disclosure(s) of information, along with the patient’s right to complain of a violation.

Protected health information includes the following and may include information that is held or transmitted in paper and/or electronic form:
A patient’s PHI may be used or disclosed by Aspen Behavioral Consulting with the written consent/authorization of the patient and/or guardian. This written consent/authorization will be obtained internally using a Release of Information (ROI), which allows the patient and/or guardian to clearly identify to whom and from whom Aspen Behavioral Consulting may release and/or obtain PHI from.

It is important to note that there are several instances, under the Privacy Law, in which Aspen Behavioral Consulting may disclose PHI without the consent of the patient and/or guardian. Permitted and required uses and disclosures that may be made without written consent/authorization, or the opportunity to agree or object to such disclosures may include:
As outlined in HIPAA, it is our responsibility at Aspen Behavioral Consulting to also inform you of your patient rights related to the protected health information that Aspen Behavioral Consulting maintains related to the services we provide and your individual records (electronic and/or paper). Please see below for a list of your rights
This notice may be amended as needed to comply with federal, state, and professional requirements. If/when Aspen Behavioral Consulting’s Notice of Privacy Practices is updated, a new copy will be provided to all patients.
Notice of Receipt of Privacy Practices
As the as the legal guardian of the patient listed above:*

I have received a copy of the Notice ofPrivacy Practices from Aspen Behavioral Consulting.I have not received a copy of the Noticeof Privacy Practices from Aspen Behavioral Consulting.
Name of Parent/Guardian:*

First NameLast Name
Date:*

MonthDayYear
Date
Signature*

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