Patient Intake Form - Cheshire Center

Haga Clic Aquí para una Versión en Español.

If your child is already being seen by one of our clinicians, CLICK HERE to fill out the correct consent form.

If you are not the patient or the legal guardian of the patient, CLICK HERE to fill out the outside referral source intake form.

Otherwise, continue below.

Patient Information
Patient Name*
First Middle Last
Patient Date of Birth*
MM slash DD slash YYYY
Legal Guardian*
Phone*
Alternate Phone
Email*
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 State ZIP Code
Patient Mailing Address
If different than address above

Street Address Address Line 2 City State ZIP Code
Person Making Referral
Referral Source Phone
Who is the patient's physician?*
Please leave the name of the physician and the practice.
Physician's Phone
Location of Services
- Home
- School / Daycare
- Office
- Teletherapy
Name of School or Daycare
Time / Availability
Does child currently receive speech services?
- Yes
- No
Does child have an IEP?
- Yes
- No
What languages are spoken in the home?*
Has your child passed a hearing screening within the last year?*
- Yes
- No
Please list when and where the screening occurred.
Please describe the concerns you have for your child.
Patient Payment/Insurance Information
If your child has Medicaid, please put their Medicaid number and select their Managed Care Organization (MCO) as well as adding the subscriber ID for their chosen organization.
Medicaid
- Medicaid
- Health Choice
- United Health Care Community Health Plan of NC
- Carolina Complete of NC
- Healthy Blue of NC
- Amerihealth Caritas of NC
- Wellcare of NC
Medicaid Number
Health Choice Number
United Health Care of NC Number
Carolina Complete Number
Healthy Blue Subscriber ID Number
Amerihealth Caritas Number
Wellcare of NC Number
Please upload a picture of the front and back of your child's medicaid card:
Front of Card
Max. file size: 300 MB.
Back of Card
Max. file size: 300 MB.
Primary Health Insurance
This insurance will be billed first if you have Medicaid
Insurance Company Name
Insurance Company Phone
Patient ID Number
Policy/Group Number
Insured's Name
First Middle Last
Insured's Date of Birth
MM slash DD slash YYYY
Insured's SSN
Please upload a picture of the front and back of your child's primary insurance card:
Front of Card
Max. file size: 300 MB.
Back of Card
Max. file size: 300 MB.
Other Primary Health Insurance
This insurance will be also billed first if you have Medicaid
Insurance Company Name
Insurance Company Phone
Patient ID Number
Policy/Group Number
Insured's Name
First Middle Last
Insured's Date of Birth
MM slash DD slash YYYY
Insured's SSN
Please upload a picture of the front and back of your child's other insurance card:
Front of Card
Max. file size: 300 MB.
Back of Card
Max. file size: 300 MB.
Where 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 Forms
Consent for Treatment
CONSENT 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 and audiology are not exact sciences and acknowledge that no guarantees have been made regarding the result of treatments or evaluations.

VIRTUAL THERAPY INFORMED CONSENT: I understand that I (legal guardian of patient) may engage in virtual therapy (teletherapy) with my Cheshire Center provider. I understand that virtual therapy services are not the same as in person therapy sessions and that to achieve the best results, I should be in a quiet place with limited interruptions when I am engaged in each session. I understand the potential risks to this technology include interruptions, unauthorized access and technical difficulties. I understand that online therapy presents unique risks to my confidentiality including variables on my end such as others in the vicinity overhearing the session or captured internet transmissions. I understand my provider will inform me and obtain my consent if another person is present during the session and I agree to inform my provider if there is another person present during the session. I understand that I cannot record virtual sessions. I understand that I may work with my provider and withdraw my consent for virtual services at any time and that my provider may terminate virtual therapy if they deem it inappropriate for me to continue under this service delivery model. I understand that Cheshire Center will make every effort to confirm that my commercial or private insurance will cover virtual therapy and that I am financially responsible. (Excludes Medicaid and NC Healthchoice)

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 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.

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 agency, LEA / 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 Consent
I 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 Contract
Thank 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 policy
Cheshire Center Attendance Policy
Therapy is most successful when the child attends and receives the recommended number of therapy sessions each week per their plan of care. Currently we have a waiting list of patients for our services and therefore must monitor and strictly enforce our attendance policy in order to maximize the time our therapists have available to serve children. POLICY: MISSING THREE OUT OF FIVE scheduled sessions will result in discharge from services. Once a patient has been discharged for attendance, they can not be referred back to our office for services for a minimum of six months and will be subject to our waitlist if applicable at the time. Some exceptions may apply.

Please openly discuss any scheduling conflicts you have with the therapist. Perhaps your current therapist, or another one will have a future opening that would be better for you if they are aware of your preferences. It is imperative to communicate.

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 a minimum of 24 hours notice is required so that our therapists can efficiently plan their day and accommodate others. We do acknowledge that sometimes life happens and cancellations are unforeseen so please notify your therapist as soon as possible if 24 hours notice is not possible. It is our intention to prevent unnecessary travel and expense on the part of the therapists therefore late cancellations will still count as missed sessions and we require your call/notification even if we see your child in daycare or preschool as sometimes the therapist is traveling to that center for a single session.

Thank you for your cooperation and consideration of our therapists’ time 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: reaton@cheshirecenter.net.
Consent*
- I have read and agree to the Consent for Treatment, Patient Information form, Payment Contract, and Attendance Policy above.
Comments
This field is for validation purposes and should be left unchanged.

Patient Information

Patient Payment/Insurance Information

Please upload a picture of the front and back of your child's medicaid card:

Primary Health Insurance

Please upload a picture of the front and back of your child's primary insurance card:

Other Primary Health Insurance

Please upload a picture of the front and back of your child's other insurance card:

Consent Authorization Forms

Consent for Treatment

Patient Information Consent

Cheshire Center Payment Contract

Cheshire Center Attendance Policy

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