Short Form: NCI 2025

Patient Name :*
Date of Birth:*

MonthDayYear
Date
E-mail*
Who is your child's Primary Care Physician:*
By checking YES below, you confirm that you are the child's legal caregiver. This document must be completed by a legal caregiver. Once you confirm you are the legal caregiver please upload your drivers license below. If you are not the child's legal caregiver and need assistance with moving forward please contact Great Strides Rehabilitation's Patient Intake Coordinator at 904-886-3228.

YesI am not the child's legal caregiver
Please upload a copy of the front of your driver's license here.*

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What language(s) does your child speak most often?

EnglishSpanishPortugueseNon-VerbalOther

Diagnosis and Clinical Information
Which therapy are you seeking for your child? (Check all that apply)

Applied Behavioral AnalysisOccupational TherapySpeech TherapyPhysical TherapyMusic Therapy
Since you are interested in ABA, please upload the diagnostic evaluation completed by a psychologist, psychiatrist, or neurologist.*

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If you do not have a diagnostic evaluation, you will need to obtain one before we can obtain authorization to see your child. Please reach out to your child's physician to obtain a referral for the appropriate provider to complete this evaluation.

If you are seeking OT/PT/ST services, please select 'no' for the above question.
A prescription from your child's primary care physician is required to request services from your insurance carrier. The prescription must contain your child's diagnosis AND the therapy you are looking to begin. Please upload the prescription here if you have it today. If you do not, please bring a copy to your first appointment.

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Primary Insurance Information *Please bring your insurance card at time of appointment*
Primary Insurance Company:*
Insured Person:*
Insured Date of Birth*

MonthDayYear
Date
Please upload a copy of the front of your insurance card here.*

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Please upload a copy of the back of your insurance card here.*

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Do you have a secondary insurance?

YesNo

Secondary Insurance Information *Please bring your insurance card at time of appointment*
Secondary Insurance Company
Insured Person :
Insured Date of Birth:

MonthDayYear
Date
Please upload a copy of the front of your insurance card here

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Please upload a copy of the front of your insurance card here

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AUTHORIZATION TO RELEASE/OBTAIN INFORMATION

I hereby authorize the release of any and all information to my insurance company or other appropriate party as required, pertaining to the treatment rendered to me by H2 Health and its affiliates. Further, I authorize H2 Health and its affiliates to obtain needed information from my physician, employer or insurance company.
Please Initial:*
Date*

MonthDayYear
Date
Your Financial Responsibility
We ask that you verify coverages for the services prescribed by your child's pediatrician. You can do that by calling the member service number on the back of the card.
All accounts are subject to a $5.00 supply charge for supplies and equipment such as toothbrushes, theraputty, modality and infection control supplies, etc. that are not generally reusable and are prepared and used on an individual basis. The cost will be included as a one time charge on your initial visit as permitted by your medical plan.

I acknowledge my understanding and agree that I am legally responsible for my account and all costs associated with the collection of my account. I understand that co-pays, co-insurance, and deductibles are due at the time of service. Any remaining account balances after insurance has been billed will be due within 30 days. If Great Strides employs a collection agency or attorney following default, then all collection fees and reasonable attorney fees may be added to my outstanding balance.

I expressly consent to receiving telephone calls from an automatic telephone dialing system, pre-recorded messages, emails, text messages, or other communication from Great Strides and/or their servicers, debt collection agencies or agents by using any telephone number, email address and/or mailing address with my account or obtained by such entities. I agree that my consent may be revoked by sending written notice to Great Strides or their agents. I agree to arbitrate any claims under the Telephone Consumer Protection Act and I waive any right or ability to bring any class action claims against Great Strides and/or their contractors, servicers, debt collection agencies or agents.

Great Strides and its affiliates strive to provide good faith estimates of what your cost will be for therapy services received at this facility. We will always verify your insurance benefits based on what you provide us at the start of care and discuss with you the findings of what your insurance plan will cover. We will inform you as best we can regarding all insurance benefit information per the guidelines stated in the “No Surprises Act”. This document is posted in our facilities and can also be found online at www.h2health.com.

If you think you’ve been wrongly billed, contact 1-800-985-3059 or visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law
I have read and understand my financial responsibility. I realize and accept responsibility for charges not covered by all of my insurances.
Please Initial :*
Date*

MonthDayYear
Date
Cancellation Policy & Tardiness
Please notify Great Strides Rehabilitation 24 hours in advance if you are unable to keep your scheduled appointment by calling the front desk at 904.886.3228.
For new patients, we are unable to reschedule you if you no show your 1st appointment .
For existing patients, If you have (3) three or more cancellations or no shows in a quarter, you will be charged a $50.00 late fee. In addition, your therapist may discharge your child.
In consideration of other patients and staff members, if you are going to be late for your appointment, please call the front desk at 904.886.3228 to ensure your therapist will still be able to see you. Your appointment may need to be rescheduled.
All therapists are scheduled with back to back appointments, therefore, If you are late dropping off or picking up your child from therapy, there will be late fee of $1.00 per minute.
Please initial that you have read and understand the Cancellation and tardiness policy:*
Who is the person that will handle the financial responsibilities for this child ?*

MotherFatherOther
I hereby give consent for treatment to be rendered to my child.
Parents Signature:*
Date:*

MonthDayYear
Date
I have been provided the HIPAA privacy Policy *
Parents Signature
Should be Empty:

Diagnosis and Clinical Information