Preschool Intake Form Preschool Intake Form Your child participated in a speech and language screening at their school. Due to their difficulty on this brief screening, an evaluation is recommended to identify if speech therapy services are needed. You will not be charged for services without your approval. We will contact you to review the results and recommendations. Please fill out this form so we can begin services promptly. Child's First Name(Required) Child's Last Name(Required) Child's Date of Birth(Required) MM slash DD slash YYYY Primary Language (if not English) School/ Childcare Facility(Required) Therapist's Name Address(Required) City(Required) State(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code(Required)Parent/ Guardian Name(Required) Phone Number(Required)Email(Required) Parent/ Guardian Name Phone NumberEmail Pediatrician Name(Required) Office Name(Required) Would you like our results sent to this person?(Required) Yes No Other physician you'd like to receive results Insurance InformationUpload a copy of the front and back of your insurance card here. If you cannot scan or take a photo of your insurance card, please call (704) 523-8027 for assistance. Please note that incomplete information will delay services for your child. FileMax. file size: 256 MB.Insurance Type(Required) Medicaid Private Insurance Medicaid Number(Required)Insurance Company(Required) Policy Holder Name(Required) Policy Holder Date of Birth(Required) MM slash DD slash YYYY ID #(Required) Group #(Required) Review of Medical and Developmental HistoryPlease answer all questions. Explain as needed. Thank you for your time and information.1. Please describe the communication concerns.2. Did early speech development seem delayed (i.e. use of single words, sentences)? Yes No Please explain 3. Please describe any unusual pregnancy, labor, or delivery. 4. If your child was born prematurely, at how many weeks gestation? 5. Does your child have a medical or behavioral diagnoses (for example, Autism Spectrum Disorders, asthma, ear infections, ADHD)? We do not discriminate based on these diagnoses, but they are relevant for determining eligibility for services and are impactful when we are planning evaluation and treatment protocols. Yes No Please explain 6. Has your child ever received a speech evaluation or speech therapy? Yes No Please explain If your child has received a speech-language evaluation from another agency, I.E.P., or I.F.S.P., please upload those documents here.Max. file size: 256 MB.Notice of Privacy Practices Charlotte Speech & Hearing Center is required by law to protect the privacy of your personal health information, provide this notice about information practices and follow the information practices that are described herein. Uses and Disclosures of Health Information Charlotte Speech & Hearing Center uses your personal health information primarily for treatment, obtaining payment for treatment, and evaluating the quality of care we provide. For example, we may use your personal health information to contact you to provide appointment reminders, or information about treatment alternatives or other health benefits that could be of interest to you. We may also use or disclose your personal health information without prior authorization for public health and auditing purposes, research studies, or for emergencies. We also provide information required by law. Your Individual Rights You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment, or other related administrative purposes. You may also request in writing that we not use or disclose your personal health information for treatment, payment, and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. We will consider all such requests on a case-by-case basis, but the Center is not legally required to accept them. Concerns and Complaints If you are concerned that Charlotte Speech & Hearing Center may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact our Executive Director at the address below. You may file a written complaint to the US Department of Health and Human Services. We will not retaliate against you for filing a complaint. Charlotte Speech & Hearing Center, Attn: Executive Director, 741 Kenilworth Ave, Ste. 100, Charlotte, NC 28204 This notice was published and becomes effective January 1, 2009. Discrimination Policy The Charlotte Speech & Hearing Center is fully committed to policies of non-discrimination. It is the practice of the center to prevent any form of discrimination, harassment, or prejudicial treatment on the basis of race, color, religion, national origin, sex, age, sexual orientation, or status of disabled individual or disabled veteran. *Borrowed from the Civil Rights Act of 1964 and the American with Disabilities Act Financial PolicyAll professional services rendered are charged to the patient. There is no guarantee of payment from any insurance company. Necessary forms will be completed to help expedite insurance carrier payment. However, this service, regardless of authorization, may or may not be covered. For this, the patient is responsible for all fees regardless of insurance coverage and must pay the entire balance, if there has been no response from your insurance company within 60 days. If your account is turned over to collections for reimbursement, a 30% fee will be charged to your balance, to cover the collection process. You will also be responsible for any attorney or court fees that may be charged in seeking retribution. A photocopy of this assignment shall be considered as effective and valid as the original. I authorize the release of any medical or other information pertinent to my case to any insurance company, adjuster, or attorney involved in this case for the purpose of processing claims and securing payment of benefits. I authorize the use of this signature on all insurance submissions. I authorize CSHC to deposit checks made in my name and authorize CSHC to disburse with the Insurance Commissioner for any reason on my behalf. I understand that I am financially responsible for all charges whether or not paid by insurance. This assignment will stay in effect as long as care is given, unless terminated by patient. Media ReleaseCharlotte Speech and Hearing Center relies on the funding of generous donors, foundations, grantors, etc. to sustain our community programs and help individuals in need who have speech-language or hearing disorders. From time to time you may be asked to provide a testimonial or speak briefly to the media as part of our ongoing efforts to support our mission. Please provide your consent below, indicating your willingness to participate. Your family’s privacy will be protected. We fully comply with federal HIPAA regulations in all cases. I hereby grant Charlotte Speech and Hearing Center (“CSHC”) the right and permission to use photographs and/or video recordings of me for the purpose of CSHC advertisements, publications, promotional flyers, educational materials, presentations, social media posts, or for any other similar purpose without compensation to me. I also understand and agree that I may be identified by first name and/or title in printed, Internet or broadcast information that might accompany the photographs and/or video recordings of me. I waive the right to approve the final product. I agree that all such portraits, pictures, photographs, video and audio recordings, and any reproductions thereof, are and shall remain the property of CSHC. I hereby I waive any right to royalties or other compensation arising from or related to the use of my image, and release CSHC and its current and former Board Members and employees from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use or distribution of said photographs and/or video recordings, including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation. I understand that permission to utilize photographs and/or recordings may be revoked at any time upon the request of the client, parent or guardian. I hereby warrant that I am eighteen (18) years old or more and competent to contract in my own name or, if I am less than eighteen years old, that my parent or guardian has signed this release form below. This release is binding on me and my heirs, assigns and personal representatives. I have read this release before signing below, and I fully understand the contents, meaning, and impact of this release. Please check as appropriate and sign belowConsent for Services(Required) I give consent for my child/family member to receive the necessary evaluation and/or treatment by Charlotte Speech and Hearing Center. * Required for an evaluation and to receive therapy.(Required)Consent to Coordinate with School(Required) I authorize CSHC to coordinate services with his/her current school, childcare facility and/or teacher.(Required)Consent to Share with CMS/UCS(Required) I authorize CSHC to share my child’s evaluation with Charlotte Mecklenburg or Union County Schools if appropriate.(Required)Consent to Share with CMS/UCS(Required) I certify that I have read this Center’s privacy practices (above) and that I have had an opportunity to review this document and ask questions. I am satisfied with the explanation and am confident that the facility is committed to protecting my/my child’s health information. This acknowledgement will remain in effect indefinitely unless otherwise revoked by written, dated request. The signature below will remain in effect indefinitely unless terminated by either the patient or Charlotte Speech and Hearing Center.(Required)Financial Policy(Required) I certify that I have read this Center’s financial policy (above) and that I am the responsible party.(Required)Payment Authorization(Required) I authorize the release of any medical information necessary to process any claim. I authorize payment of medical benefits to the physician for services rendered.(Required)Media Release Consent I grant Charlotte Speech and Hearing Center the right and permission to use photographs and/or video recordings of my child/ family member as outlined in their Media Release (above).Email Consent I grant permission for Charlotte Speech and Hearing providers to email me regarding my/ my child’s treatment (please note that email is not considered HIPAA compliant) and to send related documents via email (i.e. evaluations, treatment plans, etc.).