Step 1 of 8

Which clinic is your scheduled evaluation?*

Patient Name*

First Last

Patient Address*

Street Address City State / Province / Region ZIP / Postal Code

Patient DOB*

Gender*

Male

Female

Parent/Guardian Name(s)*

Email*

Home Phone*

Work Phone

Cell Phone

Primary Physician Name

Primary Physician Phone

Referring Physician Name

Referring Physician Phone

Support Coordinator Name (if applicable)

Support Coordinator Phone

How did you hear about AZOPT?*

Please provide additional details about your referral so we can show our appreciation:

Kids Place prefers to keep its business “in the family” when possible. Are you involved in a business that could develop a relationship with Kids Place (i.e. graphic design, office supplies, printing, construction, etc.)?

Financial Policies

AZOPT Kids Place is committed to providing the best possible care, and therefore, your clear understanding of our financial policy is important to our professional relationship. Please ask if you have questions about our fees, financial policy, or your financial responsibility.

AZOPT Kids Place will request a photocopy of the front and back of your insurance identification card and driver’s license. Please update your card with any additional information your insurance company provides, which will facilitate the submission of claims on your behalf. It is your responsibility to inform us of any changes to your policy. We will bill your insurance company on your behalf as a courtesy.

Co-Payment/Co-Insurance
We must collect your carrier-designated co-pay at the time of service. Refusal to abide by this agreement may result in termination of your coverage.

AZOPT Kids Place will calculate an estimated co-payment or co-insurance based on your insurance policy. This amount will be due at the time of each appointment.

Missed Appointments
Patients who do not show up for an appointment, or call to cancel with less than 24 hours’ notice have impacted other patient’s ability to obtain timely medical care. Therefore, subject to the individual patients’ insurance contract, we reserve the right to charge a $50.00 fee for no-show or same-day canceled appointments.

Returned Checks
If a check is used as your form of payment, and that check is returned due to insufficient funds or the payment has been stopped, you will be charged a $25.00 fee in addition to the amount of the check.

Insurance
We will gladly bill and accept payment from your health insurance plan. Any amounts not covered by your insurance carrier are your responsibility.

Communication between AZOPT Kids Place and our patients help us succeed in providing the best care. Please advise us if your insurance company has pre-certification and/or prior authorization requirements and/or policy restrictions and limitations.

Payments
You are responsible for any amount not covered by your insurance carrier. All co-payments and deductible amounts are due at the time of service. For your convenience, we do accept all major credit cards, checks, money orders, and cash.

Patient or Guarantor

I have read and understand the above. I hereby authorize Arizona Orthopedic Physical Therapy, PLLC to submit claims to my insurance carrier. I hereby authorize direct payment of benefits, otherwise payable to me, to be made payable to Arizona Orthopedic Physical Therapy, PLLC. I understand I will be responsible for payment of any amounts not covered by my insurance carrier, including, but not limited to, co-payments and deductibles.

Signature*

Parent or Guardian Printed Name*

Date*

Patient Financial Responsibility

Thank you for choosing us as your healthcare provider. We are committed to providing you with the highest quality of care. The following is a statement of our financial policy, which we require you read and agree to sign prior to any treatment.

Patient Financial Responsibilities

It is my responsibility to know my own insurance benefits, including whether AzOPT is a contracted provider with my insurance company, my covered benefits, and any exclusions in my insurance policy, and any pre-authorization requirements of my insurance company.
AzOPT will attempt to confirm my insurance coverage prior to my treatment. It is my responsibility to provide current and accurate insurance information, including any updates or changes in coverage. I am financially responsible should I not provide this information.
Estimate charges may be given at or before the time of service, but I understand that this is merely an estimate, based on information available at this time. Actual amount I will be charged for services rendered may be different from the estimate of charges for a variety of reasons, including but not limited to, additional treatments, supplies, or services not covered in the estimate.
AzOPT will bill my insurance company first, less any copayment(s) or deductible(s), and then bill me for any amount determined to be my responsibility, in accordance with my insurance policy. This process generally takes 45-60 days from the time the claim is received by the insurance company. A detailed Explanation of Benefits (EOB) is available from the insurance company when the claim is finalized.
If my insurance contract contains a Coordination of Benefits (COB) provision, it is my responsibility to contact my insurance plan and update the necessary information. I am aware that if this is not done, I am responsible for any visits not paid by insurance.
If I am uninsured, I agree to pay for the services rendered to me at the time of service. If I am unable to pay the totality of the medical services rendered at the time of service, I will make a payment plan or other payment arrangement with the clinic.
Co-pays and/or deductible payments are due at the time of service.
AzOPT will ask to make a copy of my ID and insurance cards for their records.
AzOPT accepts any form of payment – cash, check, or credit card.
In the event that a payment is missed, accounts need to be settled prior to the next appointment, or future scheduled appointments may be cancelled.

Patient or Guarantor

I have read and understand the above. I understand I will be responsible for payment of any amounts not covered by my insurance carrier, including, but not limited to, co-payments and deductibles.

Signature of Patient or Guarantor*

Date*

Kids Place Policies

Cancellation / No Show Policy
As a team we have created a plan of care for your child to meet his/her therapy needs. Following this plan of care, and attending scheduled sessions, is important in order to meet your child’s full potential. If you do not abide by the plan of care, your child may be removed from their permanently scheduled appointment. The following are examples:

Your child misses two separate appointments without our office receiving a phone call.
Failure to call and cancel your appointment at least four hours before your scheduled time is considered a no-show. We have a voice mail that is checked early so you may call after hours or early in the morning.

Your child cancels three separate appointments within one quarter, without a hospitalization or a severe illness.
Please note: a rescheduled appointment within the same week is not a cancellation.

Discharge Policy
Your child’s therapy needs may change during the course of treatment. The following conditions may result in your therapist recommending discharge from Kids Place:

Plateau in function
Kids Place is committed to creating an environment that allows each child to grow. Goals are updated each quarter based on areas of need and concerns. After each quarter, progress towards these goals is discussed with caregivers, and new/updated goals are established. If a child has reached a plateau and has not made progress in 6 months, the child may be discharged.

Meeting all goals
When a child meets all of their established goals, and there are no further functional or objective goals to meet, a child will be discharged.

I, the undersigned on behalf of the patient, have read and understand the above policies and hereby request and consent to the performance of therapy, including examination and diagnosis, of my child by Arizona Orthopedic Physical Therapy, PLLC. I consent to the treatment plan and intend this consent form to cover the entire course of treatment for my child’s present condition and for any future conditions for which we seek treatment.

Signature*

Parent or Guardian Printed Name*

Patient Name*

Date*

Authorization for the Release of Medical Records

I hereby authorize Arizona Orthopedic Physical Therapy, PLLC to release the medical record(s) of:*

Patient's DOB*

For the purpose of continued treatment and billing/re-assignment of benefits, this allows AZOPT to bill on your behalf, and for the payment to be sent directly to AZOPT, to:

Arizona Orthopedic Physical Therapy, PLLC
14557 W. Indian School Rd. #500
Goodyear, AZ 85395
Phone: 623-242-6908
Fax: 623-242-6909

Signature of Patient/Guardian:*

Printed Name*

Date*

Notice of Privacy Practices

Your name and signature below indicate that you have received a copy of and/or have been directed to the Notice of Privacy Practices by Arizona Orthopedic Physical Therapy, PLLC, on the date indicated. If you have any questions regarding the information set forth in AZOPT’s Notice of Privacy Practices, please do not hesitate to ask an AZOPT representative.

Signature of Patient/Guardian:*

Printed Name*

Date*

Photo Consent Release

I would like to extend permission to Arizona Orthopedic Physical Therapy, PLLC (AZOPT) to use my:

Name

Testimonial

Image/photograph

in publications and advertisements produced by or for AZOPT. I understand that these publications will also be placed on websites managed by AZOPT for public relations and advertising purposes. I understand that the publication may appear on the Internet, the publication may appear in print, electronic, or video media, and the publication may enable readers to identify me. I understand this consent is valid until I provide written notice stating otherwise.

Signature of Patient/Guardian:*

Printed Name*

Date*

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Emergency Contacts

Primary Insurance Information

Secondary Insurance Information

Developmental History

Financial Policies

Patient Financial Responsibility

Kids Place Policies

Authorization for the Release of Medical Records

Notice of Privacy Practices

Photo Consent Release

Form: New Patient Information – Kids Place

Emergency Contacts

Primary Insurance Information

Secondary Insurance Information

Developmental History

Financial Policies

Patient Financial Responsibility

Kids Place Policies

Authorization for the Release of Medical Records

Notice of Privacy Practices

Photo Consent Release