dev-hipaa-forms - Allcare Therapy Services, LLC

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INSURANCE INFORMATION

As a courtesy we will bill your primary insurance carrier if you provide ALL necessary
information (such as insurance cards with their CORRECT billing address and REFERRALS).
Co-pays are collected for each visit at the time of service.

Statement of Financial Responsibility

I understand my insurance carrier may not approve or reimburse my medical services in full due
to usual and customary rates, benefit exclusions, coverage limits, lack of authorization, or
medical necessity. I understand I am responsible for fees not paid in full, co-payments, and
policy deductibles and co-insurance.

PRIMARY INSURANCE

Insurance Name: *

Claims Address: *

Policyholder Name: *

Policyholder DOB: *

Marital Status: *

Policyholder Social Security #: *

Policyholder ID #: *

Patient ID #: *

Group #: *

Your First Name: *

HIPPA Required Field.

Your Last Name: *

HIPPA Required Field.

Your Email *

HIPPA Required Field.

Signature of Legal Guardian: *

For billing purposes we require this form to be fully completed. We reserve the right to reschedule
any appointments due to incomplete forms or tardiness. Thank you for your cooperation.

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Adult Intake Packet

Date of evaluation: *

Patient Information

First Name: *

HIPPA Required Field.

Last Name: *

HIPPA Required Field.

Email: *

HIPPA Required Field.

Date of Birth: *

Social Security #: *

Marital Status: *

Married

Single

Divorced

Widowed

Address: *

City: *

State: *

Zipcode: *

Specialty Doctor/Phone:

Fax #:

Primary/Family Physician:

Primary/Family Physician Phone:

Fax #:

Employer:

Employer Address:

Employer City:

Employer State:

Employer Zipcode:

Work Status: *

Retired

Student

Unemployed

Disabled

Gender *

Body Part

RX Date:

Date of Injury/Onset:

The onset date is date the first injury occurred.

Diagnosis:

Emergency Contact Name: *

Emergency Contact Phone: *

Past Medical History Questionnaire

Reason for Therapy: *

Date of Injury/Onset:

The onset date is date the first injury occurred.

Have you ever received therapy for the condition mentioned above? *

Yes

Treatment received:

Previous Treatment:

Successful

Unsuccessful

Can you be/are you pregnant?: *

Yes

Do you now or have you ever had any of the following conditions?

Conditions:

Arthritis

Hearing Loss

Osteoporosis

Depression

High Blood Pressure

Anxiety

Heart Disease

Substance Abuse

Heart Attack

Diabetes

Pace Maker

Anemia

Vascular Disease

Hypersensitivity to Hot/Cold

Stroke

Swelling in Ankles

Asthma

Deep Vein Thrombosis (DVT)

Conditions (continued):

Shortness of Breath

Seizures/Epilepsy

Chronic Cough

Metal in Body/Surgical Implants

Fainting Spells

Cancer/Tumor

Thyroid Problems

Recent Weight Loss/Gain

Headaches

Current Infection(s)

Head Injury/Concussion

Tuberculosis

Hernia

Hepatitis

Kidney/Previous Fractures

Previous Surgeries

Other

If you answered “yes” on any of the above, please explain and give approximate date(s):

Do you have any allergies:

Yes

Are you presently taking any medications?: *

Yes

Communication & Language Use

Uses Words: *

Yes

Uses Sentences: *

Yes

Omits small words (of, the, and, etc.): *

Yes

Words that seem to be difficult:

Easier words:

Most difficult communication activities:

Understands TV or radio:

Yes

Reads/Understands newspaper: *

Yes

Follows simple requests or instructions: *

Yes

Relies on Gestures: *

Yes

Relies on other means of communication: *

Yes

Do family members try to fill in words or talk for client? *

Yes

Do family members anticipate or guess client’s needs by communicating? *

Yes

Makes change or handles money: *

Yes

Gets lost in conversations or complicated instructions: *

Yes

Yes,

The information is correct to the best of my knowledge.

Signature of Patient/Legal Guardian *

Name

Child Intake Form

Date of Evaluation: *

Client First Name: *

HIPPA Required Field.

Client Last Name: *

HIPPA Required Field.

Date of Birth: *

Referral Source:

Reason for Referral:

Email *

HIPPA Required Field.

Guardian/Caregiver Name: *

Relationship to Child: *

Home Phone: *

Mobile Phone:

PHYSICIAN INFORMATION

Physician:

Physician Phone:

Physician Address:

HEALTH / MEDICAL HISTORY

Is your child in good health? *

Yes

If not, please describe medical issues:

Has your child been hospitalized? *

Yes

If so, when and why:

Does your child have a diagnosis? *

Yes

If so, explain:

Vision: *

Normal

Impaired

Wears Glasses

Contacts

Hearing: *

Normal

Impaired

Hearing Aid

Cochlear Implant

Has your child suffered from ear infections *

Yes

If so, how many and at what age?

Is Child: *

Verbal

Non-Verbal

If child is non-verbal what is the primary mode of communication?

Does child have feeding difficulties? *

Yes

If so, please describe:

Does child have difficulty swallowing (i.e. g-tube, ng-tube)? *

Yes

If so, please explain:

Does child have allergies? *

Yes

If so, explain:

List all medications child has taken in the past or is currently taking (dosage and type):

Does child employ specialized equipment at home? *

(i.e. standers, bathing/toilet chairs, wheelchairs, strollers, feeding chairs, adaptive equipment, feeding utensils, etc.)?

Has your child ever had speech/occupational/physical therapy in the past? *

Yes

What goals would you like your child to achieve during physical/speech/occupational therapy?

DEVELOPMENTAL HISTORY

Did your child exhibit any of the following behaviors during the first few years of life to a noticeable degree?

Did not enjoy cuddling

Was not calmed by being held or stroked

Feeding difficulties

Did your child fail to gain weight or grow normally?

* Check only that applies and explain if possible.

What ages did the following occur:

Stood alone:

Sat alone:

Began to babble:

Begin combining words:

Walked unaided:

Dressed and undressed self:

Crawled

Fed self with spoon:

Produced first word:

Taken off bottle:

Taken off pacifier:

Toilet Trained:

FAMILY HISTORY

Mother’s name:

Father’s name:

Mother's age:

Father's age:

Siblings: Name, Age, Gender

Is there a family history of developmental delays, speech problems, hearing loss, or learning problems? *

BIRTH HISTORY

What was the duration of the pregnancy?

Did you experience any of the following during pregnancy? *

Infections

Toxemia

Surgeries

Alcohol consumption

Smoking

Other

None

Other

Did you take any medications during pregnancy? *

Yes

If yes, please list:

What type of delivery?

C-Section

Vaginal

Were there any complications during pregnancy?

What was your child’s birth weight?

Were there complications during delivery?

Select any that apply:

Forceps

Cord around neck

Hemorrhage

RH incompatibility

Was your baby blue at birth?

Did your baby have breathing problems upon delivery? *

Yes

If yes, please describe:

Was your baby in an incubator?

Yes

Number of days:

Was your baby in the NICU?

Yes

Number of days:

HOME/ PLAY/ SOCIAL BEHAVIORS

All children exhibit, to some degree, the kinds of behaviors listed below. Please check those that you believe your child exhibits to an excessive or exaggerated degree to compared to other children of similar ages.

Hyperactivity

Does not learn from experience

Impulsivity

Head banging

Tantrums

Drooling

Low frustration tolerance

Eating inedible objects

Reduced attention span

Poor memory

Sloppy eating habits

Interrupts frequently

Nightmares

Does not listen when spoken to

Whines frequently

Sleep disturbances

Destructive

Reduced attention to danger

Staring episodes

Unusual fears (playground equipment, Accidents (falls, bumps into things), crowds, noises

Repetitive movements (hand waving, rocking, spinning)

What are your child’s favorite toys?

What types of play activities does your child enjoy most?

What toys/activities does your child dislike the most?

What activities do you enjoy doing with your child?

Does your child play with other children? *

EDUCATIONAL HISTORY

School your child is attending: *

Grade: *

What feedback have you received about your child’s school performance? *