Intake Forms — Caring Hands Pediatric Therapy LLC

HIPPA Acknowledgement

Medical Information Release

Developmental History

HIPPA Communication

Patient Profile

Child's Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Child's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Diagnosis

Parent's Name

First Name

Last Name

Email

Parents Phone Number

(###)

###

####

Therapist Name

Date of first visit

MM

DD

YYYY

Name of Child's Primary Care Physician

Physician's Phone Number

(###)

###

####

Physician's Fax Number

(###)

###

####

Name of Insurance

Effective Date

MM

DD

YYYY

Address of Insurance Company (for claims)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number of Insurance Company

(###)

###

####

Name of Policy Holder

Group ID Number (Group Name)

Policy Holder's Date of Birth

MM

DD

YYYY

Policy Holder's Social Security Number

Policy Holder's Address (N/A if same as child)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Policy Holder's Employer