Patient Intake Form Haga Clic Aquí para una Versión en Español. If you are not the patient or the legal guardian of the patient, CLICK HERE to fill out the outside referral source intake form. Patient InformationPatient Name* First Middle Last Patient Date of Birth* Date Format: MM slash DD slash YYYY Legal Guardian*Phone*Alternate PhoneEmail What are you requesting? Speech and Language Evaluation (your child has not been evaluated for speech and language services - this will determine if they need therapy) Speech and Language Therapy (you have already had an evaluation in the past year - we will request a copy of it) Patient Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Patient Mailing AddressIf different than address above Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Person Making ReferralReferral Source PhoneWho is the patient's physician?Please leave the name of the physician and the practice.Physician's PhoneLocation of Services Home School / Daycare Office Teletherapy Name of School or DaycareTime / AvailabilityDoes child currently receive speech services?YesNoDoes child have an IEP?YesNoWhat languages are spoken in the home?Has your child passed a hearing screening within the last year?YesNoPlease list when and where the screening occurred.Please describe the concerns you have for your child.Patient Payment/Insurance InformationMedicaid Medicaid Health Choice Medicaid NumberHealth Choice NumberPrimary Health InsuranceThis insurance will be billed first if you have MedicaidInsurance Company NameInsurance Company PhonePatient ID NumberPolicy/Group NumberInsured's Name First Middle Last Insured's Date of Birth Date Format: MM slash DD slash YYYY Insured's SSNOther Primary Health InsuranceThis insurance will be also billed first if you have MedicaidInsurance Company NameInsurance Company PhonePatient ID NumberPolicy/Group NumberInsured's Name First Middle Last Insured's Date of Birth Date Format: MM slash DD slash YYYY Insured's SSNWhere did you hear about our company? Speech Therapist Doctor Google Internet (Another Search Engine) Social Media Another Client Word of Mouth If you heard about us through a speech therapist, what was their name? First Last Consent Authorization FormsConsent for TreatmentCONSENT FOR CARE: I grant permission to the professional staff or their designees at Cheshire Speech & Voice Center, Inc.to render treatment or diagnostic procedures as deemed necessary during my care.I am aware that the practices of speech - language pathology, audiology and specialized instruction(CBRS) are not exact sciences and acknowledge that no guarantees have been made regarding the result of treatments or evaluations. AUTHORIZATION FOR USE OR RELEASE / DISCLOSE OF INFORMATION: I authorize Cheshire Speech & Voice Center, Inc.to release clinical information and billing information including, but not limited to, information about my diagnosis, care and treatment for the following reasons. FINANCIAL COVERAGE: To any third party or its a g ents requesting clinical and other information for the purpose of determining eligibility for insurance or other public benefits; processing insurance claims; or assessing quality, cost and appropriateness of care. USE OR DISCLOSURE FOR CONTINUED CARE: To the referring party or to any physician, therapist, extended care facility, hospital, home health care agency, LEA / school, day care, C DSA, child service coordinator, early interventionist or other such institution needing such information for continued care. AUTHORIZATION TO REQUEST INFORMATION: I authorize Cheshire Speech & Voice Center, Inc.to request any information needed for continued care from any physician, therapist, extended care facility, hospital, home health care a g enc y, LE A / school, day care, CDSA, child service coordinator, early interventionist or other such institution. AUTHORIZATION FOR RELEASE OF CURRENT CLINICAL INFORMATION: I authorize Cheshire Speech & Voice Center, Inc.to release clinical information contained in evaluations completed by a g encies other than Cheshire Speech & Voice Center, Inc.to any third party or its agents requesting clinical and other information for the purpose of determining eligibility for insurance or other public benefits; processing insurance claims; or assessing quality, cost, and appropriateness of care. AUTHORIZATION FOR PAYMENT OF MEDICAL BENEFITS: I authorize billing of insurer by Cheshire Speech and Voice Center and payment of medical benefits to Cheshire Speech & Voice Center, Inc.for services rendered. WAIVER, RELEASE, INDEMNIFICATION AND COVENANT NOT TO SUE: In consideration of Minor’ s participation in Cheshire Center programs I, in my legal capacity as parent / guardian of Minor agree on behalf of myself and Minor that The Cheshire Speech and Voice Center it’ s officers, directors, agents, employees, insurers, and representatives(“Releasees”) will not be liable for any personal injury, property damage, disability, death, sickness, or disease incurred by Minor, however occurring, including but not limited to the negligence of releases.I understand that Minor and I will be solely responsible for any loss, damage including personal injury, disability, or sickness sustained from participation in our services. I HAVE READ AND UNDERSTAND THIS INFORMATION.I HAVE RECEIVED A COPY.I AM EITHER THE PATIENT OR I AM AUTHORIZED TO ACT ON BEHALF OF THE PATIENT TO SIGN THIS FORM.Patient Information ConsentI have read and fully understand Cheshire Center's Notice of Information Practices. I understand that Cheshire Center may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time. I also understand that Cheshire Center will consider requests for restriction on a case by case basis, but does not have to agree to requests for restrictions. I hereby consent to the use and disclosure of my personal health information for purposes as noted in Cheshire Center's Notice of Information practices. I HAVE READ AND UNDERSTAND THIS INFORMATION. I HAVE RECEIVED A COPY. I AM EITHER THE PATIENT OR I AM AUTHORIZED TO ACT ON BEHALF OF THE PATIENT TO SIGN THIS FORM.Cheshire Center Payment ContractThank you for choosing Cheshire Center! We are committed to your entire experience being successful. We will need complete and accurate payment and insurance information. If you have commercial insurance or are private pay, you will need to speak to our billing specialist in order to have a general understanding of your financial responsibility prior to seeing one of our therapists. Your account balance is due upon receipt of your statement each month. We require a form of payment being placed on file prior to services being rendered. If payment is not received, it will be automatically deducted on the first Monday of the following month. Acceptable payment options include Visa, Mastercard, FSA, Care Credit, Cash and check/routing number. All returned checks are subject to a $40.00 service charge. Unpaid balances are subject to collections through an outside agency. Medicaid or NC Healthchoice patients: We do not require a form of payment on file. You are financially responsible for services rendered and a form of payment will be required to continue services should you lose your coverage. Sometimes your insurance may change during the course of treatment services. You are required to notify us immediately and provide updated information. Our billing specialist may be reached at 336-375-2240. I have read and understand the payment contract and agree to abide by this policyCheshire Center Attendance PolicyTherapy is most successful when the child attends and receives the recommended number of therapy sessions each week. Because we often have a waiting list of patients for our services, we must monitor and enforce an attendance policy in order to maximize the time our therapists have available to serve children. Please openly discuss any scheduling conflicts you have with the therapist. Perhaps the therapist will have a future opening that would be better for you if they are aware of your preferences. We require that you inform the therapist as soon as you know your child will not be available for a therapy session. Ex: upcoming vacations, field trips etc. Given advanced knowledge of such a trip, your therapist may be able to schedule an additional session to make up for the one(s) your child will miss. Cancellations with 24 hours notice is standard and preferred so that our therapists can pre-arrange their day. We do acknowledge that some things are unforeseen so please call the therapist and leave a voicemail message as soon as possible if 24 hours notice is not possible. This is applicable even if we see your child in daycare or preschool as sometimes the therapist is traveling to that center for one child only. This cuts back on unnecessary travel and expense. Our general policy for attendance even with advanced notice states that missing three out of five scheduled sessions warrants possible dismissal from therapy or the child being put on a waiting list for a more accommodating schedule. We acknowledge extenuating circumstances (ex: prolonged illness and hospitalization) and will do our best to accommodate however can not guarantee the same therapist or the same schedule if this occurs. Thank you for your cooperation and again for allowing Cheshire Center the opportunity to work with your child. Should you have any questions or concerns regarding this policy, please call the clinical director, Rebecca Eaton at Cheshire Center: 800-360-1099 or email: email@example.com.Consent* I have read and agree to the Consent for Treatment, Patient Information form, Payment Contract, and Attendance Policy above. CommentsThis field is for validation purposes and should be left unchanged.