Patient Information
Caregiver Information
Caregiver Information
Patient Background and Information Current diagnosis, practioner who gave the diagnosis, date of diagnosis
Other (Please list any medical necessities, conditions, etc. that we should be informed about)
Has this individual recieved ABA services in t he past? If so, please provide the name of the agency and when services started and ended.
Please list all current medications, supplements, vitamins, etc., including dosage and frequency.
Family Background and History Biological Mother (Name, age, and any medical conditions)
Biological Father (Name, age, and any medical conditions)
Biological Siblings (Name(s), age(s), and any medical conditions)
Insurance Information Remedy Therapy will provide a benefits check so that you can receive an estimate of coverage; however, it is not a guarantee. Insurance coverage may vary, and certain services may be excluded or subject to limitations. Ultimately, you are responsible for your payment, regardless of the initial benefits check. Please notify Remedy Therapy promptly of any changes to your insurance plan to ensure accurate billing and to minimize any potential issues with coverage and interruption of services.
Front of Insurance Card
Back of Insurance Card
Diagnosis from Physician or Psychiatrist (Diagnostic Evaluation)
Billing Inquiries Please direct all billing inquiries to:
Notice regarding Remedy Therapy's procedures and approaches ensuring the confidentiality of your health information. This notification offers a condensed overview of the potential uses and disclosures of your health information, along with the procedures for accessing such information. For comprehensive details concerning your protected health information, your entitlements, and our obligations under the Health Insurance Portability and Accountability Act (HIPAA), kindly request a complete paper or electronic copy for your reference.
You possess the entitlement to:
● Obtain a duplicate of your medical record, whether in paper or electronic format.
● Rectify any inaccuracies in your medical record, be it in paper or electronic form.
● Request confidential communication regarding your health information.
● Specify limitations on the information we disclose.
● Receive a record of individuals with whom we have shared your information.
● Obtain a copy of this privacy notice.
● Designate a representative to act on your behalf.
● Lodge a complaint if you believe your privacy rights have been infringed upon.
We might utilize and disclose your information in the following ways:
● Provide you with medical treatment
● Manage the operations of our organization
● Invoice for the services rendered to you
● Assist in addressing public health and safety concerns
● Conduct research activities
● Adhere to legal requirements
● Address matters related to workers' compensation, law enforcement, and other government requests
● Respond to legal actions and lawsuits
CONFIRMATION OF NOTICE OF PRIVACY PRACTICES RECEIPT
This form is intended for the signature of an individual legally authorized to make medical decisions for the patient concerning treatment. I have received a comprehensive copy of Remedy Therapy's Privacy Practices outlining the potential uses and disclosures of my medical and health information. I acknowledge that for any inquiries or concerns, I may reach out to the office at 302-264-3208 and communicate with the Director of ABA Services.
GUIDELINES AND CONSENT
Healthcare and Emergency Medical Situations
I acknowledge that Remedy Therapy mandates the involvement of a closely associated physician in the medical care of every child. I have either already secured or will arrange for the necessary medical care with a physician.
Mandated Reporting
I understand that all personnel at Remedy Therapy are obligated reporters and are mandated, by law, to notify authorities of any confirmed or suspected instances of child abuse or neglect.
Communication Policy (Consent for Email Use)
HIPAA, which stands for the Health Insurance Portability and Accountability Act, was enacted by the U.S. go vernment in 1996 to institute privacy and security safeguards for health information. All data stored on our computers and transmitted internally at Remedy Therapy is encrypted.
While information sent via email from Remedy Therapy is not encrypted , federal guidelines permit the transmission of personal medical information via unencrypted email if the patient is informed about the associated risks and provides consent. I am aware of the risks of unencrypted email and grant permission to Remedy Therapy to send me personal health information through unencrypted email. I retain the right to revoke this consent at any time by submitting a written request.
Consent for Assessment and Treatment
By signing below, all parents/guardians authorize a behavioral evaluation and treatment for the patient named below. All parties have reviewed and accepted the aforementioned office policies.
Shared Custody Notification
Recognizing that many families have situations involving shared custody, please attach any documentation detailing your child's living arrangements. This information is crucial for us to offer appropriate support and involve all relevant parties, such as custody reports or multi-home schedules. Kindly submit custody documents if necessary, below.
Legal Guardianship or Conservatorship Notification
For clients aged 18 or older under the care of a legal guardian or conservator, please provide documentation verifying guardianship or conservatorship. Kindly submit appropriate documents if necessary, below.
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