Milestones ABA Intake Form
We must have the following in order to start services:
Today's Date
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Month
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Day
Year
Date
Location Preference
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Birmingham Office
Gulf Shores Office
Springville Office (Private funding Only; No insurance accepted)
Telehealth (online) Caregiver Training
Name of Patient
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First Name
Last Name
Name of Parent/Guardian
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First Name
Last Name
Parent/Guardian Email
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example@example.com
Patient's DOB
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Funding Source
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Insurance
Private Pay
(If you selected insurance, please complete the next two questions with policy information. If you selected private pay, please write N/A for both questions below.)
Insurance Provider
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(if you selected private pay above, write N/A)
Patient's Insurance ID or Contract Number
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(if you selected private pay above, write N/A)
Insurance Group Number
Insurance Card FRONT
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Insurance Card BACK
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Patient's Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Phone Number
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Area Code
Phone Number
Diagnoses ex; Autism, ADHD
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If no diagnosis, type N/A. Insurance will not cover ABA without a formal Autism diagnosis and report
What are your main concerns for your child and what would you like to achieve through therapy?
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Diagnosis Given By (MD, PhD, PsyD Name)
Diagnosis Date
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Month
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Day
Year
Date
Medical Doctor Name
Medical Doctor Practice Name
Medical Doctor Phone Number
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Area Code
Phone Number
Medical Doctor Fax Number
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Area Code
Phone Number
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone 1
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Area Code
Phone Number
Emergency Contact Phone 2
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Area Code
Phone Number
Medication and dosage
Other health concerns/diagnoses
Parent/Legal Guardian Consent and Agreement for Emergencies: As parent/legal guardian, I give consent to have my child receive first aid by MBG staff, and, if necessary, be transported to receive emergency care. I understand that I will be responsible for all charges not covered by insurance. I agree to review and update this information whenever a change occurs and at least once a year.
Name of School Currently Attending
Current Grade in School
Does your child have an IEP? Insurance companies require a copy of IEP with submission of treatment request. Please upload below
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Current Fees for Service
Private pay services are billed as follows:
Payment and Attendance Policies & Agreements
REQUIRED: By signing below, I am agreeing that I understand the fees for service chart above and will pay these rates when billed as a private pay client or an insurance client paying for no-call/no show fees or late cancellations, and I am agreeing to adhere to Milestones Policies on attendance.
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REQUIRED: Consent to Provide Therapeutic Services I am providing consent to receive Applied Behavior Analysis Services. I give consent for Milestones Behavior Group, Inc. to provide ABA services. I understand that I may request clarification, ask questions, and/or terminate services at any time.
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REQUIRED: INSURANCE- CMS 1500 Box 12 & 13: Authorization to Release Information for Claims: I authorize the release of any medical or other information necessary to process claims submitted for services rendered to my child/family by Milestones Behavior Group, INC., and I authorize payment of medical benefits to Milestones Behavior Group, INC for their services.
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REQUIRED: CONSENT FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR PAYMENT, TREATMENT, AND HEALTH CARE OPERATIONS: By signing below, you hereby consent for Milestones Behavior Group, INC to use or disclose information about yourself and/or your child (or another person for whom you have the authority to sign) that is protected under federal law, for the sole purpose of treatment, payment and health care operations.
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REQUIRED: Agreement to Participate in Parent Training: I agree to participate in ABA parent training for a minimum of one hour per month for each month that my child receives ABA services at Milestones.
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Consent for Media Release (optional): I give Milestones Behavior Group, Inc. permission to use my child, children, or individuals for whom I am legal guardian’s photograph and/or video in its promotional materials, and in training materials. I understand that the photograph and/or video may be used in publication, print ad, direct mail piece, electronic media (e.g., video, cd-rom, DVD, Internet, www), or other forms of promotion. I release Milestones Behavior Group, Inc. employees and designees from liability for any violation of any personal or proprietary right I may have in connection with such use. I am 18 years or age. I understand that this release is optional and will in no way affect the rendering of said services.
REQUIRED: ATTENDANCE: ILLNESS/ EMERGENCIES/CANCELLATIONS: Our policies are designed to protect the integrity of your child’s treatment program. All parties reserve the right to cancel sessions due to holidays, illness, and emergencies. We will always inform you at least 24 hours ahead of time if we need to cancel or reschedule a session(s) unless there are precluding limitations to doing so. We expect that if you need to cancel or reschedule your child’s session, that you call/text/email us as soon as you are aware of the change. If we do not receive a 24-hour notification of your cancellation or you fail to show up for an appointment, then you will be charged for the full total of the appointment, as well as place your child’s services at risk. No Call-No Show is defined as the parent/caregiver failing to inform Milestones via email, text or phone call/message that he or she will be late or cancelling with 24 hours notice. Emergency situations are handled on a case by case basis. For late arrivals, our therapists will not be available to perform sessions once 15 minutes of the scheduled time has passed without the child arriving (or caregiver logging on for telehealth sessions) for therapy and the family will be charged the full session amount. For late pickups, we do not have staff available to look after your child after their scheduled pick-up time has passed. You must pick your child up on time. Two late pick-ups will result in termination of services. We cannot provide your child therapy if he/she is or has been ill or has had a fever of 100.00 or above and until he/she is fever/symptom free for 24 hours. You must inform Milestones of your child’s wellness status within 24 hours of the scheduled session time in order to refrain from accumulating a No-Call/No-Show. Additionally, if your child misses 20% or more of his or her scheduled sessions in a given month without a Doctor’s excuse(s), services will be terminated.We recognize all national holidays and do not provide make-up sessions for sessions missed on these days. Our policies are designed to protect the integrity of your child’s treatment program. They will be strictly enforced.
Attendance Policy
REQUIRED: By signing below, you are agreeing to adhere to Milestones attendance policy.
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Required File Uploads
Diagnostic Evaluation Report showing your child's diagnosis (ex; Autism F84.00), IEP from School if applicable, Insurance Card (front and back), Speech/OT Evaluations if applicable AND all sections in this form completed/signed. WE WILL NOT BE ABLE TO CONTACT YOU IF THESE DOCUMENTS ARE NOT UPLOADED. THEY ARE REQUIRED BY INSURANCE COMPANIES TO APPROVE and COVER PAYMENT FOR SERVICES. You may also email them to: therapy@milestonesaba.com
Diagnostic Evaluation Report if applicable
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Insurance will not cover ABA without a formal Autism diagnosis and report.
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Speech-Langage, Occupational Therapy, Physical Therapy and/or ABA Therapy Reports if applicable
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Individualized Education Plan (IEP)
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Other Medical reports if applicable
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ABA Telehealth Services & Parent Training
For Office Use Only
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