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Any questions, please call the office at 704-846-0262
Insurance Please type N/A if the required field does not applyMedicaid number: Medicaid ID number* Commercial/Private Insurance Company: Name of Insurance Company*Commercial/Private Insurance Company Phone Number: Area Code and Phone Number * Policy ID:Policy ID Number * Group Number: Group Number* Policy Holder Name: Policy Holder Name * Policy Holder DOB: Date of birth* Is the policy holders address the same as above? Yes/No* If no, what address? Street Address City State Zip
Additional Insurance Additional Insurance Company:Insurance company name Additional Insurance Company phone number: Phone number Policy ID: Policy ID number Group Number: Group Number Policy Holder Name: Policy holder name Policy Holder Date of Birth: Policy holder DOB Policy Holder Address if Different from Above? Address if different
EARLY BIRD OPENING PAPERWORK PACKET
Client Name: First Name* Last Name* Name Of Person Filling Out Form: First Name* Last Name* Relationship to Child: Relationship*
Early Bird Consent for Treatment, Payment and Operation
I give my voluntary consent for Early Bird Developmental Services to use and disclose health information regarding your child's name* to carry out treatment, payment and health care operations. In addition to sharing health information with my insurance company/Medicaid if requested and acquiring physician orders, I authorize Early Bird Developmental Services to exchange health information with the following agencies or person(s): anyone we can share information list* (list out any agencies with whom we can exchange information such as your pediatrician, school, etc.)
Consent for Treatment, Payment, and Operations
By signing this form, I am consenting to Early Bird Developmental Services' use of and disclosure of my child's protected health information for treatment, payment, and health care operations. I understand that I do not have to consent to the use or disclosure of my child's protected health information for treatment, payment, and health care operations, but if I do not consent, Early Bird Developmental Services may refuse to provide me health care services. I understand that I can request more information at any time about how Early Bird Developmental Services uses or discloses protected health information to carry out treatment, payment, and health care operations. I understand that I can revoke this consent at any time. This consent is effective until the above-named client is discharged by Early Bird.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This is a summary. For the full text of this notice visit www.earlybirdonline.com. For more information or assistance, or to request a printed copy of the full text this notice, contact Robert Kornfeld, Director of Operations, 704-9995-2929 or firstname.lastname@example.org
You have the right to:
You may permit - or deny us permission - to use and share your information in certain ways. Without express written permission WE WILL NOT:
Our Uses and Disclosures
We may use and share your information as we:
FINANCIAL RESPONSIBILITY, BILLING & PAYMENT
It is your responsibility to pay for all services rendered. We are in-network with most major insurance companies and will file our claims with your insurance company or another payer for services rendered on your behalf. We will verify your insurance benefits with your carrier and provide you with a good-faith estimate of your out-of-pocket costs for our services, but it is important to understand that we do not guarantee this information. Insurance companies do not guarantee payment; payment is determined at the time we file each claim (each time a service is provided).
Knowing your benefits is ultimately your responsibility, and we strongly encourage you to call your insurance company directly or use an online portal to review your benefit information as it applies to our services. If you have a change in insurance or Medicaid status, you must inform your therapist or call the office immediately at 704-846-0262. Failure to make us aware prior to change will result in your liability.
Once we have received a reply from your insurance or other payer for each claim, we will bill you on the 15 th of each month for your portion of our charges, if any. (This process can take several weeks.) Please do not pay your therapist directly.
If you prefer, an interest-free Equal Payment Plan is available. You may pay your out-of-pocket costs in 12 or 24 equal monthly installments. A credit/debit/HSA will be kept on file and automatically charged each month. You will get a receipt for each payment by email and continue to receive monthly statements showing all charges and credits.
To request paperless statements or set up an Equal Payment Plan, please contact Bob Kornfeld at 704-995-2929 or email@example.com. To pay your bill online go to www.earlybirdonline.com and look for the “Make Payment” tab at the top of the page. Unpaid balances may incur late charges or lead to suspension of services. Delinquent balances or returned checks may be referred for collection and incur additional costs.
Please initial here to indicate that you have carefully read and understand Early Bird’s Financial Responsibility Policy:
Early Bird expects parents and caregivers to be active participants in therapy so that techniques demonstrated can be incorporated into your child’s daily routine.
Therapy may be provided in your child’s natural environment or in our clinic. In the natural environment the therapist may occasionally bring toys or other materials (books, adapted toys, etc.) that in their professional opinion might enhance your child’s development.
Therapy sessions are typically 30 to 60 minutes once or twice a week depending on medical necessity and specified treatment plans. This time may include direct therapy, parent or caregiver education, and consultation to ensure that all parties are involved in the treatment process.
It is Early Bird’s policy to provide Medicaid members with limited English skills the language assistance necessary in order to afford them meaningful and equal access to the Medicaid benefits and services to which they are entitled, in accordance with Title VI of the Civil Rights Act of 1964 (42 U.S.C. §§2000 et. seq.) and regulations pursuant thereto (45 C.F.R Part 80).
YOUR QUESTIONS AND CONCERNS
In order for us to be successful in our intervention, we must work together and have an open and honest relationship. If you are having difficulty regarding scheduling appointments, treatment techniques used, or any other aspect of the therapeutic process, please express your concerns to your therapist, or directly to Sherry Kornfeld at info @earlybirdonline.com or 704-846-0262.
I acknowledge by signing below that I have read and understand the Early Bird Client Guide to Company Policies:
This document contains important information about our decision (yours and mine) to resume in-person services during the COVID-19 pandemic. We will return to teletherapy services if lockdown orders are again imposed by local, state or federal authorities, if other health concerns arise, or at any time you or I feel it is safer to do so.
By Signing below, I acknowledge that there are risks associated with in-person services during a pandemic.
Our responsibilities to minimize exposure
To begin or resume in-person services, I agree to take certain precautions which will keep everyone (you, me, our families, and other patients) safer from exposure to the virus that causes COVID-19. If we do not adhere to these safeguards, it may necessitate a return to teletherapy services.
This agreement supplements the original Consent for Treatment, Payment, and Operations that I signed at the start of our work together. Your signature below indicates that you agree to the above conditions.
I hearby consent to engage in telehealth with Early Bird Developmental Services for my childs as part of their therapy couse of care. I understand that "telemedcine or telehealth" includes the pracice of health care dleivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or date communications. I understand that telehealth also involves the communciation of my medical/mental information, both orally and visually, to health care practitioners. In understand that that I have the following rights with respect to telehealth:
1. I have the right to withhould or withdraw consent at any time without affecting my right to future care or treatment and without risking th eloss or withdrawal of any benefits to which I would otherwise be entitled.
2. The laws that protect confidentiality og my medical informatoin also apply to telehealth. As such, I understand that the informatoin disclosed by me during the course of my therapy is generally confidential.
3. I understand that there are risks and consequences from telehealth, including but not limited to, the possibility, despite reasonable efforts on the part of my therapists, that: the transmission of my medical information could be distrupted or distorted by tachnical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic strorage of my medical information could be accessed by unauthorized persons.