Preschool Intake Form Preschool Intake Form Child's First Name(Required) Child's Last Name(Required) Child's Date of Birth(Required) MM slash DD slash YYYY School/ Childcare Facility(Required) Gender(Required)FemaleMaleTransgenderI prefer not to identify my genderRace(Required)American Indian or Alaskan NativeAsianBlack/African AmericanHispanic/Latino/Spanish originMiddle Eastern or North AfricanPacific IslanderWhite/ CaucasianTwo or More RacesOtherI prefer not to identify my racePrimary Language (if not English) Address(Required) Neighborhood i.e. Steele Creek, Westerly Hills, CotswoldCity(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) Pediatrician Name(Required) Office Name(Required) Would you like our results sent to this person?(Required) Yes No 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) Physician Name on Card(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.Please describe the communication concerns.Did early speech development seem delayed (i.e. use of single words, sentences)? Yes No Please explain 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. Therapy Attendance PolicyConsistent attendance is the key to success in therapy, but we understand that there will be times when you or your child must miss a therapy appointment. If you called your therapist at least two hours in advance to cancel the session, a make-up session can be completed and should be scheduled at the time of cancellation. Those absences must be made up within 30 days. If you do not cancel in advance, your visit will not be made up. Make up sessions with your therapist will be a priority, but there may be times when a different therapist will need to complete the make-up session. If you miss a make-up session, it cannot be scheduled again. Therapists who must cancel therapy will make their best effort to find another therapist to see your child. Should an absence occur due to illness that involves a fever being present, do not return to therapy until 24 hours have passed with no sign of fever. Also, if your child has vomited or has a condition that can be spread through touch or air, you will need to keep the child home until symptom free for 24 hours. Office closures due to weather will be announced on our voicemail. Your therapist will also try to contact you. If our office is open, you are expected to attend therapy unless it is unsafe for you to travel. We do not operate on a school or county calendar. If our office is open, you are expected to keep your appointment. Clients who miss more than 15% of their therapy sessions at home, online, in the office, or at school will be discharged following a verbal or written warning from the therapist. If you determine at a later date that you would like to resume therapy, please contact our office. If you need to stop or pause therapy, one week’s notice is required before discontinuing therapy.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)Financial Policy(Required) I certify that I have read this Center’s therapy attendance policy (above). I understand that this service may be only partially covered or not covered by my health care benefits plan and accept full financial responsibility for any balance due.(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)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.).
