New Patient Intake Form CHILD INFORMATION PARENT/GUARDIAN INFORMATION Name Mother Date of birth Age DOB Home Ph Gender Doctor Cell Ph Work Ph Person Referring Mailing Address Medical Diagnosis City, State, Zip Current immunizations? Yes No Physical Address If “NO” give reason City, State, Zip Child resides with? Parents Foster Occupation Who has custody of child? Parents OCS Employer OCS Caseworker. Name Father Cell DOB Home Ph Person other than parent Name Cell Ph Work Ph bringing child to therapy. Cell Mailing Address PRIMARY INSURANCE INFORMATION City, State, Zip Primary Insurance Physical Address Policy Number City, State, Zip Group Number Occupation Expiration Employer Claims Address May we send out an appointment reminder via text ☐ ☐ or unencrypted email? Yes No ☐ Text Cell ph #: ______________________________ Phone Number ☐ Email Email Address:__________________________ Insured’s Name ☐ Both Insured’s DOB May we email (not encrypted) requested medical SECONDARY INSURANCE INFORMATION records or therapist communication to you? Secondary Insurance Yes No Email Address:______________________ I authorize AKT, KKT, and/or ORS to submit bills directly to Policy Number the insurance carrier(s) for payment. Group Number I authorize insurance carrier(s) to make payments to AKT, Expiration KKT, and/or ORS. Claims Address I understand that KKT and/or ORS may be billing the Infant Learning Program (ILP) for my child while enrolled in ILP. Once my child is discharged from ILP, I hereby give KKT Phone Number and/or ORS permission to bill my insurance carrier(s) Insured’s Name directly for payment. Insured’s DOB Parent or Legal Guardian Date Signature
New Patient Intake Form CHILD INFORMATION PARENT/GUARDIAN INFORMATION Name Mother Date of birth Age DOB Home Ph Gender Doctor Cell Ph Work Ph Person Referring Mailing Address Medical Diagnosis City, State, Zip Current immunizations? Yes No Physical Address If “NO” give reason City, State, Zip Child resides with? Parents Foster Occupation Who has custody of child? Parents OCS Employer OCS Caseworker. Name Father Cell DOB Home Ph Person other than parent bringing child to therapy. Name Cell Ph Work Ph Cell Mailing Address PRIMARY INSURANCE INFORMATION City, State, Zip Primary Insurance Physical Address Policy Number City, State, Zip Group Number Occupation Expiration Employer Claims Address May we send out an appointment reminder via text or unencrypted email? ☐ Yes ☐ No ☐ Text Cell ph #: ______________________________ ☐ Email Email Address:__________________________ ☐ Both May we email (not encrypted) requested medical records or therapist communication to you? Yes No Email Address:______________________ I authorize AKT, KKT, and/or ORS to submit bills directly to the insurance carrier(s) for payment. I authorize insurance carrier(s) to make payments to AKT, KKT, and/or ORS. I understand that KKT and/or ORS may be billing the Infant Learning Program (ILP) for my child while enrolled in ILP. Once my child is discharged from ILP, I hereby give KKT and/or ORS permission to bill my insurance carrier(s) directly for payment. Phone Number Insured’s Name Insured’s DOB SECONDARY INSURANCE INFORMATION Secondary Insurance Policy Number Group Number Expiration Claims Address Phone Number Insured’s Name Insured’s DOB Parent or Legal Guardian Signature Date
01_printable_intake_2018.docx