New Patient Registration 2025 A

Crane Rehab Center New Patient Registration
1. (A) Parent/Legal Guardian #1 Full Name*
1. (B) Phone Number*
Please enter a valid phone number.
1. (C) Email for Guardian #1
example@example.com
1. (D) Relationship to Patient *
Only legal guardians or court-appointed custodians may complete this form. Other family members should not submit this form.
1. (E) Parent/Legal Guardian #1*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. (A) Is there a second parent/legal guardian involved?*

YesNo
1. (F)- Parent/Legal Guardian #2 Full Name*
1. (G)-Phone Number Guardian #2*
Please enter a valid phone number.
1. (H) Email for Guardian #2*
example@example.com
1. (I) Relationship to Patient for Guardian #2*
Only legal guardians or court-appointed custodians may complete this form. Other family members should not submit this form.

2. (B) Are parents divorced or separated?*

YesNo
3. Who is financially responsible for medical care?*
4. Who is authorized to sign consents?*
5. Patient's Full Name*
6. Patient's Date of Birth*

MonthDayYear
Date
7. Patient's Gender*
8. Patient's Sex at Birth
9. Formal Diagnosis. If your child does not have one, please enter N/A.*
10 (A). Please write full name of Homeschool, Daycare, Preschool, School
10 (B). Grade (N/A, if not applicable)
11. Preferred Pediatric Clinic Location*
Keep us in mind if you need adult services. We have two locations: 101 River Road, Suite 112, Jefferson, LA 70121 and 1055 St. Charles, New Orleans, LA 70130
12 (A). Referring Doctor's Full Name*
12 (B). Referring Doctor's Phone Number*
Please enter a valid phone number.
13. Referral or Legal Guardian Concerns*

14. Do you plan to use your insurance, or will this be self-pay?*
Upload a copy of your Insurance Card (Front & Back)*

Cancelof

SELF-PAY- SECTION
Crane Rehab Center – Self-Pay Agreement
Patient's Name
Legal Guardian Name
ACKNOWLEDGMENT OF SELF–PAY STATUS

By signing this form, I agree to pay for my therapy services myself and I hereby remove Crane Rehab from the
responsibility of billing my insurance carrier, if applicable.

We at Crane Rehab want you to make an informed decision regarding our self-pay rules and regulations.

By signing below, you agree to the following:
• Payments for all services and supplies are due at the time of service.
• Crane Rehab Center, LLC will not retroactively submit a claim to an insurance provider for services rendered.
• At any time per your request, we can provide you with a patient statement for you to submit to your insurance or for tax purposes. Please note that some insurance carriers require authorization prior to services being rendered and may not accept a self-pay statement. You may want to discuss this with your
insurance carrier before agreeing to the self-pay discount.

PATIENT AGREEMENT

I agree to pay personally for therapy services and elect not to have my insurance billed. I agree to be personally and fully responsible for any and all charges accrued related to the delivery of therapy treatments. I understand that I may not go back and choose to have a previous session switched from self-pay to insurance
billed charges. It is my right to request future sessions be billed through insurance, but I am responsible for communicating that request in writing to Crane Rehab. I understand and agree to the above stated terms. I understand that insurance filing is done as a courtesy to me, and I have chosen to opt out of this option.

By signing below, I acknowledge that I have read and understand the above and have been given the opportunity to ask questions. I confirm that I am the legal guardian, or the legal guardian's duly authorized representative.
Legal Guardian Signature:*

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DateTime

Check All Services Needed*

Occupational Evaluation (Ages: 15 months to 3 years)Occupational Evaluation (Ages: 4 to 12 years)Occupational Evalution (Ages 13 and up)Feeding Occupational (for sensory processing difficulties or self-feeding skills)Speech EvaluationFeeding Speech Evaluation (for issues like tongue tie.....).Physical Evaluation

Background Information
Patient's Full Name
Patient's Date of Birth

MonthDayYear
Date
Parent/Legal Guardian #1 Full Name*
Parent/Legal Guardian #2 Full Name
Parent’s/Guardian’s occupation(s):*
Person giving report: *
Language(s) spoken in home: *
Patient's Sex at Birth*

FemaleMale
Current preferred gender pronouns *

List all persons living in the household:*
Referring Physician: *
Diagnosis:*
Reason for referral*
Is this diagnosis the result of an accident?*

YesNo
What type of accident?

AutoOther
Date of Injury

	Full Name
Pediatrician:
ENT:
Neurologist:
Psychologist/Psychiatrist:
Orthopedist:
Geneticist:
Immunologist:
Gastroenterologist:
Physical Therapist
Occupational Therapist:
Speech Therapist:
Dentist:
Other:

	Age
Baby Cereal?
Baby Food?
Finger Food?
Friendliness

CRANE REHAB CENTER INTAKE NOTICES
INSURANCE INFORMATION
At the time of registration or anytime during your treatment, it is your responsibility to inform Crane Rehab Center, LLC of any changes to your insurance coverage. You are also responsible for verifying that your insurance provider processes payments promptly. Fulfilling this responsibility may require direct communication with your insurance company.

If your insurance plan requires prior authorization, you must ensure that you have received current authorization for the dates of your service. While we will assist you by processing claims and obtaining authorization, if applicable, you are ultimately responsible for the accuracy and timeliness of your account.

TREATMENT CONSENT & AUTHORIZATION
I, the undersigned (patient or responsible party), hereby voluntarily authorize Crane Rehab Center, LLC to provide wellness services, conduct outpatient evaluations, perform procedures, and administer therapy or medical treatments deemed necessary or appropriate by the attending physician or consulting allied health provider. I acknowledge that medical treatment and therapy are not exact sciences, and no guarantees have been made as to the outcome of any care or treatment provided.

AUTHORIZATION TO RELEASE INFORMATION
I, the undersigned (patient or responsible party), hereby authorize Crane Rehab Center, LLC to release medical record information via telephone, reproduction, email, or facsimile regarding outpatient therapies, treatments, evaluations, and/or medical services to:

-Referring physicians for treatment status
-Family physicians providing follow-up care
-Third-party payers for substantiating medical necessity and verifying charges
-Case managers for determining medical necessity or conducting utilization reviews

ASSIGNMENT OF BENEFITS
In the event that I am entitled to any outpatient benefits through insurance or another claim or policy, I irrevocably assign these benefits to Crane Rehab Center, LLC for application toward my bill(s). I request that payments of these benefits be made directly to Crane Rehab Center, LLC

PAYMENT GUARANTEE
I understand that participation by Crane Rehab Center, LLC with my insurance company does not guarantee payment for services. Pre-authorization is not a guarantee of benefits or eligibility, and some services may be denied due to plan limitations, medical necessity, or other policy restrictions.

I am responsible for paying any amounts not covered by my insurance provider. Any outstanding balances will be due upon receipt of notification from Crane Rehab Center, LLC.

Co-payments, deductibles, and coinsurance are due at the time of service. I understand that any coverage estimates provided by Crane Rehab Center, LLC are approximations and that I am ultimately responsible for any amount not covered by my insurance, regardless of whether it aligns with the quoted estimate.

This statement will servive as Advance Beneficiary Notice.

Failure to keep my account current may result in therapy services being placed on hold until payment is received. Accounts with balances exceeding 30 days may be subject to additional fees and interest charges at a rate of 1.5% per month. Returned checks will incur a $25.00 service fee.

INSURANCE, INDEMNITY INSURANCE, AND OTHER THIRD-PARTY LIABILITY CLAIMS:

As a courtesy, we will contact your insurance provider or other third-party payer to attempt to determine your benefits prior to your first therapy visit and prior to purchasing any medical supplies or equipment. However, any quoted benefits are not a guarantee of payment. You are ultimately responsible for any expenses incurred if your insurance does not pay.

If your injury is determined to be accident-related and the insurance denies payment, you will be held 100% responsible for the payment of all charges related to services received at Crane Rehab Center, LLC.

NOTIFICATION OF INSURANCE CHANGES:

It is your responsibility to notify Crane Rehab Center, LLC of any changes to your insurance coverage during the course of your treatment. We will submit claims to your insurance company based on the information provided, and you will be responsible for any changes that occur.

MISSED EVALUATION APPOINTMENT POLICY: 48 HOUR NOTICE CANCELLATION/NO SHOW FEE

We are committed to providing the highest quality evaluation experience possible.
Evaluations are scheduled as one-on-one appointments with a therapist in the appropriate discipline (Physical Therapy, Occupational Therapy, Speech Therapy, or Applied Behavior Analysis). Because these sessions require preparation and time reserved exclusively for your appointment, cancellations made with less than 48 hours’ notice, or failure to attend the appointment, will result in a $125 fee.

MISSED TREATMENT APPOINTMENT POLICY: 24 HOUR NOTICE AND CANCELLATION/NO SHOW FEE:

At Crane Rehab Center, LLC, we are dedicated to your well-being and treatment progress. In return, we ask that you honor your plan of care by attending all scheduled therapy sessions. Consistent participation plays a vital role in achieving the best therapeutic outcomes.

• 24-Hour Notice:
We kindly request at least 24 hours’ notice to cancel or reschedule an appointment. Please contact our Front Desk Coordinator to make any scheduling changes.

• Cancellation Fee:
Cancellations made with less than 24 hours’ notice will incur a $25.00 fee per scheduled therapy session. For example, if you are scheduled for two therapies in one day, the total fee will be $50.00.

• No-Show Fee:
If you do not attend a scheduled appointment without prior notice, a $75.00 fee per therapy session will apply. For instance, if two therapies were scheduled that day, the total no-show fee will be $150.00.

• Attendance and Compliance:
Consistent attendance is essential to your treatment success. If you miss more than 25% of your scheduled sessions within a given time frame (e.g., per month), or if attendance becomes inconsistent, you may be discharged from therapy or placed on a waiting list.

ELECTRONIC COMMUNICATION, ACKNOWLEGDEMENT & AGREEMENT

Crane Rehab Center, LLC communicates with patients via electronic communications/messages, including but not limited to, email, online portals, and other digital platforms. These communications may include, among others, appointment reminders, progress notes, initial evaluations, discharge summaries, and other medical information related to your care.

I understand that the transmission of Protected Health Information (PHI) via electronic communication, including email or web-based messaging, involves certain risks. While Crane Rehab Center, LLC utilizes a HIPAA-compliant secure server for transmitting PHI, I acknowledge that once PHI is sent through email or electronic messaging systems, there is a potential for unauthorized access or redisclosure, and the information may no longer be protected by federal confidentiality laws. Additionally, I recognize the risk that unintended recipients may acquire PHI, even if it is accompanied by a medical confidentiality disclaimer.

By signing the intake Notice Form, I acknowledge that I have read and understand the risks associated with the transmission of electronic communications/messages. I agree to hold Crane Rehab Center, LLC, its staff, and affiliates harmless from any liability, loss, injury, or damages arising from or related to the transmission, receipt, or misuse of electronic communications/messages containing PHI.

I hereby consent to receive electronic communications from Crane Rehab Center, LLC, understanding the potential risks involved.

PATIENT’S RIGHT TO CHOOSE PROVIDER

You have the right to choose among available providers and to change providers at any time, within the limits of health insurance, medical assistance, and/or other health programs. All therapies at Crane Rehab Center, LLC are "at-will" services and may be discontinued at any time by the patient, with or without cause.

DISCONTINUATION OF SERVICES

Crane Rehab Center, LLC reserves the right to discontinue therapy services if treatment is outside the scope of our staff's expertise, if therapy is no longer appropriate, if attendance is poor, if staff is subjected to harassment, or if payment or insurance information is not properly updated. In such cases, Crane Rehab Center, LLC will provide referrals for alternative services as needed.

LEARNING/ EDUCATION SITE

As part of our commitment to education, Crane Rehab Center, LLC partners with various universities to provide clinical instruction. You or your child may receive treatment from a student clinician, but rest assured, all care provided by students is closely supervised by a licensed therapist to ensure your treatment plan is never compromised.

PERSONAL PROPERTY

Crane Rehab Center, LLC is not responsible for any loss or damage to personal property. Patients are solely responsible for their personal items brought to our facilities. This includes, but is not limited to, electronics, wheelchairs, lifts, and toys.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (1996) NOTICE OF PRIVACY POLICY (NPP) AND PRACTICE ACT FOR PROCTED HEALTH INFORMATION (PHI)
PURPOSE OF THIS NOTICE

Crane Rehab Center, LLC is committed to safeguarding the privacy and confidentiality of our patients' Protected Health Information (PHI). We understand the importance of maintaining the privacy of your health information and have always been diligent in our efforts to protect it. In compliance with the Health Insurance Portability and Accountability Act (HIPAA), we are required to provide you with written notification regarding how we may use and disclose your PHI. Please be assured that we remain steadfast in our commitment to maintaining your privacy and confidentiality.

TYPES OF PERSONAL HEALTH INFORMATION (PHI) WE COLLECT

Each time you visit Crane Rehab Center, LLC, a record of your visit is created. This record typically includes your initial evaluation, diagnosis, treatment plan, recommended exercises, modalities, and frequency of treatments. This Protected Health Information (PHI) is commonly referred to as your medical record or chart and serves as the foundation for your ongoing care and treatment.

In addition to treatment information, your PHI may also include authorizations, insurance forms, billing information, and other identifying information such as name, date of birth, gender, social security number, address, and phone numbers (home, work, or mobile). This information may also include reports, test results, and consults from other medical facilities.

We retain this information for a minimum of 10 years, as required by law, and we limit the collection of personal information to that which is necessary to provide you with quality medical care, as well as for insurance and reimbursement purposes.

HOW WE PROTECT PERSONAL INFORMATION

We protect your PHI by limiting access to only those employees and contractors who need to know this information to provide effective treatment and facilitate documentation for reimbursement and insurance purposes. Each employee of Crane Rehab Center, LLC is required to sign a Confidentiality Agreement, acknowledging their understanding of their responsibilities in maintaining the confidentiality of your information.

DISCLOSURE AND USES OF PHI FOR TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS

We may use and disclose your PHI for the purposes of treatment, payment, and healthcare operations as permitted by law. For example:

-Treatment: Our therapists may share your health information with other healthcare professionals involved in your care, including the referring physician, to coordinate your treatment and ensure the best possible outcomes.
-Payment: We may disclose PHI for the purpose of billing your insurance provider or any third-party payer. This includes submitting diagnosis codes, treatment codes, and other necessary information to process your claims.
-Healthcare Operations: We may use your PHI for purposes related to our operations, such as quality assessment, audits, and training.

COMMUNICATION WITH FAMILY AND GUARDIAN

For patients who are minors, or for those with designated guardians, we may communicate with parents, guardians, or authorized representatives regarding treatment, appointment reminders, and referral questions. This includes sharing updates on the patient’s progress or treatment plan with the referring physician. However, in the case of divorced or separated parents, we will communicate with both parents unless a court order is provided specifying otherwise. If a court order restricts access to information or designates one parent or guardian as the sole contact, we will comply with the terms of that order.

SPECIAL CIRCUMSTANCES

We may disclose PHI in certain circumstances, including but not limited to:

· To comply with public health laws or regulations, such as reporting infectious diseases or preventing harm to public safety.

· As required by law for judicial or administrative proceedings, including subpoenas, discovery requests, or other legal processes.

· For peer review and operational assessments.

We do not disclose your PHI to any third parties outside of those specified without your written consent.

INDIVIDUAL RIGHTS TO YOUR PERSONAL HEALTH INFORMATION

You have the right to access and inspect your PHI by submitting a written request to Crane Rehab Center, LLC. You may review your records during an appointment, under the supervision of our staff.

You also have the right to request corrections or amendments to your PHI. If we deny your request, you have the right to file a statement of disagreement, which will be included with future disclosures of your PHI.

PRIVACY POLICY AMENDMENT

Crane Rehab Center, LLC reserves the right to amend this Privacy Notice at any time. Any changes to this notice will be posted in our lobby and made available to you upon your next visit.

POSTING OF OUR PRIVACY NOTICE

Our Privacy Notice is prominently displayed in our waiting area and provided to each patient for review and signature at the time of registration

FILING A COMPLAINT

If you have any questions about this Privacy Notice or would like to file a complaint regarding the handling of your PHI, please contact the Director of Administrative Services, Sonja Jorgenson, at 504-828-7696 or email sjorgenson@cranerehab.com.

If you believe your privacy rights have been violated, you have the right to file a complaint with the U.S. Department of Health and Human Services (HHS).

CRANE REHAB CENTER INTAKE NOTICES ACKNOWLEDGMENT

By signing below, I acknowledge that I have read, understand, and agree to comply with all policies and procedures outlined in the intake documents, including the attendance and cancellation policy.
Signature*

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Date

MonthDayYear
Date

Thank you for completing our new patient forms! Please ensure your Pediatrician has sent your child’s prescription to us via fax at

504-866-6991 or email at pediatricintake@cranerehab.com.We look forward to seeing you soon!
Should be Empty:

	YES	NO	AGE ACQUISITION
Roll from stomach to back
Roll from back to stomach
Sit independently
Pull to stand
Crawled (on hands and knees)
Stand independently
Cruised along furniture
Walked independently
Dresses self
Babbling and cooing

	Name of Medication	Dosage	Frequency/Duration	Route of Administration	Date-Changes-D/C
1
2
3
4
5
6
7
8
9
10

	YES	NO	COMMENTS
Has difficulty with snaps, zippers, button
Has difficulty opening/closing food or drink containers/packaging
Has difficulty removing and/or putting on clothes
Potty Trained? (if yes, specify age in comment) Has/had difficulty potty training

	YES	NO	COMMENTS
Seems weaker or tires more easily than other children their age
Clumsy or seems not to know how to move body, bumps into things
Hesitates to climb or play on playground equipment
Has difficulty pumping self on swing
Has difficulty peddling age-appropriate bicycle (tricycle, training wheels, 2-wheels)

	YES	NO	COMMENTS
Has difficulty holding pencil (i.e. poor pencil grasp)
Seems to have too tight/too light pencil grasp (i.e. rips papper, breaks pencils, can't see words)
Fatigues quickly in writing or other pencil or paper tasks
Hand dominance not well established (after age six)
Has difficulty manipulating small objects easily (i.e. Legos, potato head pieces, stacking blocks)

Crane Rehab Center New Patient Registration

Background Information

Birth/Health History:

Speech Clinical Case History

School Age Occupational Checklist (Ages 4 to 12)

Toddler Age Occupational Checklist (Ages 15 months to 3 years)

Pediatric Feeding History Form

Food Range Diary

	YES	NO	COMMENTS
Uses too much force when playing with toys or interacting with other children/pets
Has trouble keeping hands to self, will pull or push other children
Touches things constantly; "learns" through fingers
Avoids putting hands in messy substances (i.e. finger painting, glue, or Play-Doh)

	YES	NO	COMMENTS
Has difficulty naming or matching colors, shapes, or sizes
Has difficulty in completing puzzles; trial and error of placement of pieces
Has reversals in words or letters after first grade
Difficulty coordinating eyes (i.e. keeping place reading, copying from board to desk)
Seems to bring their head too close to written work

	YES	NO	COMMENTS
Appears to have difficulty in understanding or paying attention to what is said to them
Has trouble reading
Has trouble following 2-3 steps commands

	YES	NO	COMMENTS
Does not accept changes in routine easily
Difficulty getting along with other children
Marked mood variations, tendency to have outbursts or tantrums
Has trouble controlling their interactions in group games such as tag, dodge ball
Has trouble participating in busy or group situations (i.e. cafeteria, circles time)

	YES	NO	COMMENTS
Does not want to wear clothing/diapers or becomes significantly distressed with clothing/diaper changes
Refuses or has a strong dislike of wearing shoes
Distressed during any part of the bathing process; specify in the comments
Does not notice pain following falls, bumps, or bruises
distressed with hair or fingernail grooming/trimming: specify in comments

	YES	NO	COMMENTS
Appears to be in constant motion
Craves upside down play
Frequently spins self
Extreme fear of heights or climbing
Enjoys crashing/falling on purpose

	YES	NO	COMMENTS
Eats only foods of a certain texture
Eats/mouths things that are not food (i.e. dirt, paper, pet food, paint chips)
Gags when eating or presented with food

	YES	NO	COMMENTS
Avoids eye contact
Sensitive to bright lights (cries, covers/closes eyes)
Distressed in response to fluorescent lights (i.e. at the grocery store)
Visually perseverates on toys, objects, screens

	YES	NO	COMMENTS
Becomes distressed when changing from one activity to another
Needs advance notice several times before a change in routine happens
Difficulty separating from parents/caregivers
Difficulty calming self (given strategies from caregiver)

	YES	NO	COMMENTS
Difficulty using spoon/fork
Difficulty using open cup (after 18 months old)
Difficulty staying seated for mealtimes

	YES	NO	COMMENTS
Requires extensive help to fall asleep (i.e. rocking or holding for longer than 1 hour; requires a car ride; stroking hair/back for prolonged periods)
Difficulty staying asleep at night
Co-sleeps with others
Does not nap daily or not consistently

	YES	NO	COMMENTS
Does no assist caregiver with removing clothing
Does not assist caregiver with putting on clothes
Difficulty with washing or drying hands (with assistance)
Difficulty with participating in tooth brushing (with assistance)
Is not aware nor bothered by soiled pants/clothing

	YES	NO	COMMENTS
Difficulty Playing appropriately with peers (i.e. biting/hitting/pushing)
Easily distracted during play; has fleeting attention
Prefers to play alone
Does not imitate simple play schemes or gestures (i.e. pat-a-cake)

	Time of Feeding (Start Time)	NG, G, or Continuous	Amount	Gravity or Pump?	Over what time period or rate
1
2
3
4

	YES	NO	COMMENTS
Difficulty following 2-3 step play
Difficulty using imaginative play
Difficulty sustaining attention during play longer than 2 minutes