2025 WEBFORM INQUIRY

New Patient Request

Behavior Matters Consulting SC is pleased to offer Speech and ABA services for your child. Please fill out the form below, thank you for your help and cooperation!
Requested Therapy:

SpeechFeedingABASocial GroupsParent Training
Therapy Availability:*
Child's Legal Full Name:*

First NameMiddle NameLast Name
Child's Nickname*
Primary Language*
Child's Date of Birth*

MonthDayYear
Date
Child's Legal Guardian / Parent:*

First NameLast Name
Guardian's Email Address*
Guardian / Parent Phone Number*
Please enter a valid phone number.
Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature*

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What current services does your child receive?
How often do they receiving the services indicated above?*

Medical History*

	Yes or No	Additional Information
Does your child have a medical diagnosis?

Insurance

Insurance*

	Current Accepted Insurance
Please indicate your insurance

Primary Insurance*

	Yes or No	Please explain
If insurance is not listed above , please provide insurance name
Who is the primary Insured?
What is the Insured's date of birth?
What is the Policy Number? (include letters)

Secondary Insurance*

	Yes or No	Please explain
Do you have Secondary Insurance? Who is Carrier?
Who is the primary Insured?
What is the Insured's date of birth?
What is the Secondary Policy Number? (include letters)

Optional : Insurance Card and Diagnosis

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Notice of Privacy (HIPAA)

This notice describes how medical information about you may be used, disclosed and how you can gain access to this information. Please review it carefully.

This notice is being provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). This notice describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, and healthcare operations and for other purposes that are permitted or required by law. PHI includes any of your written or oral health information including demographic data that can be used to identify you.

Understanding Your Health Information

Each time you receive health related services a record is made of the treatment. Typically, this record contains your diagnosis and treatment notes. This information, often referred to as a health, treatment or medical record, serves as a:

*Basis for planning your care

*Means of communicating among the health professionals, e.g. therapists or physician who *contribute to your care

*Legal document describing the care you received

*Means by which you or a third-party payer can verify that services billed were provided

Your Health Information Rights

Although your health record is the physical property of Behavior Matters Consulting SC, the information belongs to you. You have the right to:

*Request a restriction on uses and disclosure of information as provided by 45 CFR 164.522

*Receive confidential communications of health information as provided by 45 CFR 164.522

*Inspect and copy your health record as provided for in 45 CFR 164.522

*Request to amend your health record as provided in 45 CFR 164.522

*Obtain an accounting of disclosure of your health information as provided in 45 CFR 164.522

*Revoke your authorization to use or disclose health information except to the extent that action has already been taken

*Obtain a paper copy of the notice upon request

The right to make a request does not guarantee it will be granted. The request may be denied based on certain situations; including but not limited to: emergency treatment and disclosures to the Secretary of the Department of Health and Human Services. All requests must be made in writing.

Behavior Matters Consulting SC’s Responsibilities:

*Maintain the privacy of your protected health information (PHI)

*Abide by the terms of this notice

*Notify you if we are unable to agree to a requested restriction

*We will not use or disclose your health information without your authorization, except as described in this notice: We will only use your health information for treatment and billing.
Notice of Privacy (HIPAA): By signing below, I have read and fully understand the content and authorization release and hereby agree to and authorize the foregoing provisions:*

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New Patient Request

Insurance