SLA PATIENT INTAKE FORM

Welcome!

Thank you for choosing Elevate Health & Therapeutic Services.
This form is intended to collect the following necessary information in order for us to best serve you.
1. Patient Information
2. Physician Information
3. Financial Responsibility Information
4. Insurance Information
5. Credit Card Information
6. Consent and Acknowledgement Forms
Please have the above information available while filling out this document.

We are required by law to have many of these forms on file. If you have any questions regarding any of these forms, please feel free to contact us via email at info@elevatehealthnj.com.

We greatly appreciate your time and effort to thoroughly complete this information - thank you!
Name of person completing form*

First NameLast Name
Relationship to patient*
(e.g., spouse, child; or 'self')
This patient is a:*

Minor (under 18 years of age)Adult (over 18 years of age)
Patient Information

Please provide the following information about the patient and the primary contact methods.
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Preferred communication method

MobileWorkEmailText
Preferred email to contact*
example@example.com
Preferred phone to contact*
This will be used for appointment reminders.
Primary address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Information

	Name	Relationship to Client	Phone Number
Contact

Please check which of our services you are interesting in pursuing at this time.

ABA (Applied Behavior Analysis)AudiologyFeedingOccupational TherapyPhysical TherapyAAC TherapySpeech Therapy
Referral Information

Please provide the following information to help us know how you found us.
How did you hear about us?*

DoctorOther healthcare providerWebsiteFacebookInstagramPatientOther
If you selected 'Doctor', 'Patient', 'Other' or 'Other healthcare provider,' please indicate the name below.
Physician Information

Please provide the following information regarding your primary care providers.
Primary Doctor*
Group Practice Name
Address of Physician/Practice*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Physician/Practice*
Please enter a valid phone number.
I give consent for Elevate Health & Therapeutic Services to communicate with the above-mentioned provider.*

Yes
Financial Responsibility Information

Please provide information on who is financially responsible for the provided services.
Name*

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Information

Please provide the following information regarding insurance policies. Please be advised that if you are a military patient, you have the option to bypass the requirement of uploading a picture of your military ID by instead uploading a blank photo.
Name of insurance company*
Policy Holder*
Relationship to Patient*
Policy Holder's SSN
Policy Holder Date of Birth*

MonthDayYear
Date
Group Number (GRP)
ID*
Patient's ID # (if available)
Copy of Insurance Card - Front*

Cancelof
Copy of Insurance Card - Back*

Cancelof
Do you have a secondary insurance provider?

YesNo
Name of insurance company
Policy Holder
Relationship to Patient
Policy Holder's SSN
Policy Holder Date of Birth

MonthDayYear
Date
Group Number (GRP)
ID
Patient's ID # (if available)
Copy of Insurance Card - Front

Cancelof
Copy of Insurance Card - Back

Cancelof
Payment Policy Agreement
As a courtesy, Elevate Health & Therapeutic Services verifies your insurance benefits. Please note that a benefits quote is not a guarantee of payment; claims will be processed according to your specific plan. If your insurance processes the claim differently than quoted benefits, the insurance company's decision will prevail.

Payment is due at the time of service unless prior financial arrangements have been made. Patients are required to pay their deductible, copayment, coinsurance, and any outstanding balances at each visit. Refunds will be issued if a credit occurs.

For patients covered by our contracted health insurance carriers with applicable benefits, we will submit claims on your behalf. However, accepting your insurance does not transfer financial responsibility to the practice, and you are accountable for any unpaid balances determined by your plan. Typically, we charge your credit card on file for outstanding balances 10 days after receiving the Explanation of Benefits from your insurer. Please note, we do not send automated monthly statements by mail for payment requests.

While we are contracted with multiple insurance carriers, coverage may vary. A referral to our clinic does not guarantee coverage under your insurance plan, and you are fully responsible for all charges incurred. Physician referrals and our verification of your insurance benefits do not ensure payment.

If we do not participate with your insurance carrier, you are responsible for payment at the time of service. You may request a service receipt for direct submission to your insurer by emailing billing@elevatehealthnj.com. Upon request, Elevate Health & Therapeutic Services will provide additional service information as needed for insurance claims.

Failure to submit payment may result in suspension of services until the account is settled in full. A late fee of 1.5% per month may apply to unpaid balances starting 30 days after the initial statement. A $35 fee will be charged for returned checks. Delinquent accounts may be referred to a collection agency, and you agree to cover any associated collection charges and legal fees.

You must notify Elevate Health & Therapeutic Services of any change in insurance coverage or attending physician.
Cancellation & No-Show Policy
We are committed to delivering excellent care to our patients. To maintain consistency, we have establisted a patient No-Show/Cancellation Policy that all patients are required to follow. When you schedule an appointment, that time is reserved specifically for you. If an appointment is missed or canceled on short notice, it prevents the clinic from accommodating another patient during that time.

To avoid incurring the cancellation/no-show fee, please contact our office at 856-492-1355 at least 24 hours prior to your scheduled appointment. This allows us to reschedule your appointment and make the time available for another patient. If you miss your appointment or cancel with less than 24 hours' notice, Elevate Health & Therapeutic Services reserves the right to charge a $60 cancellation/no-show fee per appointment. Please note, this fee is non-negotiable, the responsibility of the patient or responsible party, and is not billable to insurance.

Additionally, if a patient is more than ten (10) minutes late to their appointment, we reserve the right to cancel the appointment and apply the cancellation fee.

We understand that emergencies may occasionally arise, and we will address these situations with you as they occur. Thank you for working with us to ensure that we can provide the best possible care to all our patients.

Illness

If you or your child are sick and cannot come to the clinic, please inquire about our teletherapy appointment option. If teletherapy is not suitable, the appointment must be rescheduled within two weeks of the initial session to avoid the cancellation fee.

We appreciate your understanding and will be happy to reschedule your appointment. We recognize that sudden illnesses may occasionally occur and will address these situations with you as needed.

Inclement Weather

During inclement weather, our primary goal is to ensure the safety of our staff and patients. The clinic will decide whether to remain open or close based on weather conditions. If the office remains open, you may switch your scheduled appointment to a teletherapy visit if applicable. If teletherapy is not an option, the appointment must be attended or rescheduled within two weeks to avoid the cancellation fee. If the office determines that the weather poses a hazard to staff and patients, we will close the clinic and notify all patients.

Vacations

We recognize that patients may take breaks from services for vacations. If you and your family plan to be away, we kindly request advance notice to cancel scheduled appointments. Failure to provide such notice may result in a $60 charge per missed appointment.

We make every effort to accommodate rescheduled appointments with your current clinician(s). However, if they are unavailable, we will offer alternative availability with another qualified staff member for the appropriate service. Opting not to reschedule with another therapist(s) may result in being charged our cancellation fee.

Due to our increasing waitlist, we enforce a limit of three (3) missed appointments within a six-week period. It is essential that you or your child adhere to the treatment plan prescribed by your clinician. Failure to comply may lead to the cancellation of remaining appointments and consideration for a flexible scheduling arrangement for future sessions.
By clicking "yes" below, I confirm that I have carefully read and understand each policy of Elevate Health & Therapeutic Services. I agree to accept any applicable fees or charges resulting from non-compliance with these policies.*

Yes
Credit Card Authorization
We request that all patients provide a credit card at the time of their initial evaluation (excluding Audiology Evaluations). This is a standard procedure, and the card will be kept on file regardless of patient responsibility. We assure you that we will not charge the card without first notifying the responsible party. Our office is committed to working with families in cases where patient responsibility or cancellation fees cannot be paid in full at the time of charge.

Please be aware that it is the responsibility of the patient or responsible party to promptly inform Elevate Health & Therapeutic Services of any updates or changes to credit card information, including address, zip code, updated expiration dates, account numbers, and security codes.
By signing below, I acknowledge that I have reviewed and understand Elevate Health & Therapeutic Services' policy requiring all patients to maintain a credit card on file and to provide payment information at the time of my or my child's initial evaluation. I authorize Elevate Health & Therapeutic Services to charge the credit card provided in this authorization for any unpaid balances in accordance with the terms outlined in the Payment Policy Agreement. I confirm that I am an authorized user of the credit card I will provide and agree not to dispute payments with my credit card company, as long as the transactions align with the terms specified in this form and/or Elevate Health & Therapeutic Services' payment, and cancellation/no-show policies.
Signature*
Name*

First NameLast Name
Date*

MonthDayYear
Date
Consent & Acknowledgment Forms
COMMUNICATION TERMS

Regarding the individual named above, I give permission for the therapist/Elevate Health & Therapeutic Services to...
1. Communicate with me regarding therapy sessions (including progress, attendance, scheduling, etc.) via text, email, and voicemail.
2. Communicate with me via email regarding therapy. Some emails may include PDF attachments and Word documents which may or may not be password protected.
I understand that...
1. If I want my child’s therapist to communicate with anyone other than the parent/guardian of the child indicated on initial paperwork, I will sign and authorize consent to do so. I will request Elevate Health & Therapeutic Services to do so in writing.
2. If a divorce or separation situation exists, a custody agreement and separation agreement will need to be shared with Elevate Health & Therapeutic Services and my child’s therapist. I will share custody agreements with my therapist/Elevate Health & Therapeutic Services so that my therapist only shares information with legal guardians of my child.
3. My child’s invoice for speech services will be emailed to the provided email. Information containing diagnosis codes, procedure codes, dates of service, cost of service and insurance plan information will be included on these invoices.
4. My child’s pediatrician will be sent orders for signature, as well as plans of care and progress notes.
I accept the above communication terms.*

Yes
PERMISSION TO SCREEN, EVALUATE AND/OR PROVIDE THERAPY

Evaluations consist of standardized testing, informal and formal observations, and clinical judgment. Treatment is based upon the findings of the evaluation and the recommendations of the responsible treating clinician.
I, the parent/guardian or patient, authorize Elevate Health & Therapeutic Services, to screen, evaluate and/or provide the necessary treatment/therapy/services to the below named individual.*

Yes
Patient Name*
Privacy Notice Acknowledgement

Elevate Health & Therapeutic Services is legally obligated to maintain the confidentiality and security of your health information, which may encompass:
- Notes from your doctor
- Medical history
- Test results
- Treatment notes
- Insurance information
We are mandated by law to provide you with a copy of our privacy notice. Please keep this notice for your records as it details how your health information may be utilized or disclosed, and outlines procedures for reviewing and commenting on your information.
By selecting 'Yes,' you confirm that you have received a copy of our privacy notice.*

YesNo
Sensory Gym Policies and Waiver

Elevate Health & Therapeutic Services has established policies to ensure our clients have both a fun and safe experience while participating in therapy using our sensory gym. Please review the following policies. Should you have any questions or require clarification on our procedures, please feel free to contact our office via email at info@elevatehealthnj.com or by phone at 856-492-1355.
- No food, drink, or gum is allowed in the sensory gym.
- No shoes on the mats (except for shoes needed to position orthotics).
- Siblings are not allowed on any equipment if present during evaluations or treatment.
- All children and families must be accompanied by a therapist when in the gym.
- Parents are welcome to observe their child in the sensory gym; however, we ask that they remain seated in the chairs located in the gym.
- The use of the equipment and mats is reserved for the treating child and the therapist only.
Sensory Gym Release Waiver and Assumption of Risk

I hereby give consent for my child to participate in the sensory gym activities at Elevate Health & Therapeutic Services. I understand that engaging in these activities carries a risk of injury during treatment and evaluations. I acknowledge and accept the potential risks and damages that may arise from my child's participation at Elevate Health.

Nevertheless, on behalf of myself, my child, and our heirs, administrators, and executors, I release, indemnify, and hold harmless Elevate Health and all associated persons or entities from any and all responsibility or liability for claims, demands, damages, costs, causes of action, and expenses (including reasonable attorneys' fees) arising from my child's participation in therapy or evaluations at Elevate Health. This includes but is not limited to personal injury, disability, or property damage sustained during or as a result of treatments or evaluations.

I understand that any medical costs resulting from an accident must be covered by the participant’s family medical insurance policy.
I confirm that I fully understand and agree to the terms outlined above regarding my child's participation in therapy and evaluations at Elevate Health & Therapeutic Services.*

Yes
Please sign and date below to acknowledge completion of this form. Thank you!
Name*

First NameLast Name
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Welcome!

Patient Information

Referral Information

Physician Information

Financial Responsibility Information

Insurance Information

Payment Policy Agreement

Cancellation & No-Show Policy

Credit Card Authorization

Consent & Acknowledgment Forms