New Patient Forms

The following forms and corresponding instructions have been provided for your convenience. Please note that these forms may not be the appropriate forms for all patients in all circumstances.

New Patient Forms

New patients can save time during their first appointment by completing the Patient Registration form prior to their visit.

NEW PATIENT INTAKE FORM

PATIENT INFORMATION

First
MI
Last
Address *
Address
City
State/Province
Zip/Postal

REFERRING SOURCE

First Name
MI
Last Name

PARENT|LEGAL GUARDIAN

Parent | Legal Guardian First Name/Middle Name
Parent | Legal Guardian Last Name
Relation to Client

INSURANCE *** MUST BE FILL ***

YOUR HEALTH CARE PROVIDER, INSURER, OR PLAN MAY REQUIRE A PHYSICIAN REFERRAL OR PRIOR AUTHORIZATION AND YOU MAY BE OBLIGATED FOR PARTIAL OR FULL PAYMENT FOR THERAPY SERVICES PROVIDED.

AUTHORIZATIONS and ACKNOWLEDGEMENTS

HIPPA: Notice of Privacy Practice
By signing this statement you are acknowledging that you have had the opportunity to receive HIPAA Notice of Privacy Practices:
Signature Parent/Legal Guardian or Self

INSURED OR AUTHORIZED PERSON’S SIGNATURE:

Signature:

PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE:

I hereby authorize the release of any necessary information to process insurance claims, including medical and billing information, as well as to discuss the child’s case information with other Therapists working within the building structure of CARROUSEL THERAPY CENTER CORPORATION to/from, from/to the referring physician, Therapist Co-workers and insurance company.

Scheduling

(for first time appointments)
Please list all days and times your child is available:

CHILD CASE HISTORY FORM

GENERAL INFORMATION:
Full Name
Full Name
Child’s Address
Child's Address
City
State/Province
Zip/Postal

The family requests that results of this evaluation should be sent to:

Please complete consent form to allow us to do this.
Which services are you requesting?

THERAPY PRECAUTIONS

Please be specific
Does your child have any food allergies?
If your child has Down’s Syndrome, has he/she been diagnosed with Atlantoaxial instability?
Are there any precautions not listed above that we should know about.

FAMILY HISTORY

Full Name
Were there any illnesses, injuries, bleeding, or any complications during this pregnancy?
Are Parent’s?
(chose One)
Have there been any instances of the following in your immediate or extended family members:
(Check All that Apply)

PREGNANCY AND BIRTH HISTORY

Were there any illnesses, injuries, bleeding, or any complications during this pregnancy?
Was this pregnancy full-term?
Was labor and delivery normal?
Did your child experience jaundice?
Was there need for oxygen or respiratoryassistance?
Were there difficulties with feeding?
Did your child bottle-feed or breast feed?
Did your child have difficulties sucking?

MEDICAL HISTORY

Has your child had any of the following illnesses?
Meningitis
Chicken Pox
Seizures
Frequent Ear infections
Excessive vomiting or reflux.
Cleft Palate
Does your child have vision problems?
Does your child use any adaptive equipment?
Is your child on any medications?

GROWTH AND DEVELOPMENT

What age did your child:
ADD ANY COMMENTS
ADD ANY COMMENTS
ADD ANY COMMENTS
ADD ANY COMMENTS
ADD ANY COMMENTS

PATIENT SERVICE AGREEMENT

SIGNATURE: PARENT/LEGAL GUARDIAN

New Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operations

( the term “I” refers to the Parent/Legal Guardian of child) understand that as part of my healthcare, “Therapy,” originates and maintains paper and/or electronic records describing “my” (the term “my” refers to parent and/or child) health history, symptoms, examinations and test results, diagnoses, treatment, and any plans for future care of treatment. I understand that this information serves as: -A basis for planning my care and treatment, -A means of communication among the many health professionals who contributes to my care, -A source of information for applying my diagnosis and surgical information to my bill, -A means by which a third-party payer can verify that services billed were actually provided, and -A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcareprofessionals. I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges: -The right to review the notice prior to signing this consent, -The right to object to the use of my health information for directory purposes, and -The right to request restrictions as to how my health information may be used or disclosed to carry out treatment,payment, or healthcare operations. I understand that “Therapy,” is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations. I further understand that “Therapy,” reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should “Therapy,” change their notice, they will send a copy of any revised notice to the address I’ve provided (whether U.S. mail or if I agree e-mail).
I understand that as part of this organization’s treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax and/or e-mail.
Parent/legal Guardian’s Signature
FOR OFFICE USE ONLY

HIPPA Release Form

Print Name Of Parent/Guardian
give permission to “CARROUSEL THERAPY CENTER” and all employees to discuss and/or receive medical information including medical records concerning any and all aspects of patient’s previous healthcare by a doctor, physical, occupational or speech therapist, or other medical professional. This release is required to obtain medical information according to the privacy rule detailed in HIPPA (The Health Insurance Portability and Accountability Act of 1996).

Credit Card Agreement

All parents and guardians are responsible for paying their child’s co pay and deductibles, set by their Insurance Company. These fees are nonnegotiable. Unless otherwise specified, we will collect these fees every session. We have made this process easier by accepting Visa card, Master card, American Express card, and Discover card. By signing below it is agreed that your credit card number will remain on file and “Carrousel Therapy Center Corporation” will charge that credit card only in the event that your child attends his or her therapy session. A receipt will be provided to you for all charges applied. We hope this makes everything easier for you to keep track of your fees. Thank you,

Or you can simply print out the Patient Registration form, fill in the information requested, and bring the completed form with you to your appointment.

Download Form Here