Behavioral Services Client Intake Form
IMPORTANT! Please Read and understand the following statement from the Centers for Medicare and Medicaid Services:
"By law, the Medicaid program is the payer of last resort. If another insurer or program has the responsibility to pay for medical costs incurred by a Medicaid-eligible individual, that entity is generally required to pay all or part of the cost of the claim prior to Medicaid making any payment." (From: https://www.cms.gov/regulations-and-guidance/legislation/deficitreductionact/downloads/tpl.pdf)
This means we must try to get services authorized and paid for through your private health insurance before going throuh Medicaid, and before we begin providing service. If you fail to disclose private health insurance information, know that ABA claims may be denied by Medicaid in which case you will be financially responsible for the entire amount due. If, on the otherhand, you disclose private health insurance and it does not include a benefit for ABA, does not cover the entire amount, or includes deductibles, co-pays or co-insurance, we can then bill medicaid for any amounts that would otherwise be your responsibility. Again, this only works if we know about your private health insurance beforehand, so please help protect yourself from unexpected financial burdens later by giving us all possible insurance information now.
Below, please add each family member who plays an active, significant role in the individual’s life. Normally this will include yourself, other parent/guardians, and siblings. You may also include relatives or friends who provide care on a regular basis and would ideally know the details of strategies being used in behavior therapy. The form allows you to add up to six family members. If you need to add additional people please call our intake coordinator at (720)469-2967.
Below, list each treatment that has been provided to your child, starting with current or most recent treatments. The form allows you to add up to 5 different treatments. If you would like to add more, please contact our intake coordinator at (720)469-2967.
Indicate below the age at which the child attained each of the following developmental milestones. If you are uncertain of the age, select whether it was reached earlier or later than normal.