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REQUEST APPOINTMENT
Arizona Orthopedic Physical Therapy
Physical Therapy
AzOPT
The AzOPT Difference
Physical Therapy
Aquatic Therapy
What We Treat
How We Treat
Free Assessments
KIDS PLACE
The Kids Place Difference
Pediatric Physical Therapy
Pediatric Occupational Therapy
Pediatric Speech Therapy
Pediatric Feeding Therapy
Pediatric Aquatic Therapy
Mariah’s Miracle
LOCATIONS
AzOPT Aquatics
AzOPT Buckeye
AzOPT Gilbert
AzOPT Glendale
AzOPT Goodyear
AzOPT Prescott
Kids Place Central (Phoenix)
Kids Place East (Gilbert)
Kids Place North (Prescott)
Kids Place West (Goodyear)
FOR PATIENTS
AzOPT FAQs
Kid’s Place FAQ’s
Direct Access
New Patient Forms
Insurance and Billing
Pay My Bill
Notice of Privacy Acts
EDUCATION
Blog
Newsletters
ABOUT
Our Story
Our Team
Community Involvement
Careers
Contact
AzOPT
The AzOPT Difference
Physical Therapy
Aquatic Therapy
What We Treat
How We Treat
Free Assessments
KIDS PLACE
The Kids Place Difference
Pediatric Physical Therapy
Pediatric Occupational Therapy
Pediatric Speech Therapy
Pediatric Feeding Therapy
Pediatric Aquatic Therapy
Mariah’s Miracle
LOCATIONS
AzOPT Aquatics
AzOPT Buckeye
AzOPT Gilbert
AzOPT Glendale
AzOPT Goodyear
AzOPT Prescott
Kids Place Central (Phoenix)
Kids Place East (Gilbert)
Kids Place North (Prescott)
Kids Place West (Goodyear)
FOR PATIENTS
AzOPT FAQs
Kid’s Place FAQ’s
Direct Access
New Patient Forms
Insurance and Billing
Pay My Bill
Notice of Privacy Acts
EDUCATION
Blog
Newsletters
ABOUT
Our Story
Our Team
Community Involvement
Careers
Contact
Form: New Patient Information – Kids Place
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Which clinic is your scheduled evaluation?
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Kids Place West
Kids Place Central
Kids Place East
Kids Place Prescott
Home Visit
Patient Name
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First
Last
Patient Address
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Street Address
City
State / Province / Region
ZIP / Postal Code
Patient DOB
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MM slash DD slash YYYY
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?
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Doctor - Provided Options
Doctor - Direct Referral
Returning Patient
Insurance
Family/Friend
Word of Mouth
Community Event
Internet Search
Social Media- FB, Newsletter
Advertisement
Fitness Partner
AZOPT Employee
Drive By
Yellow Pages
Other
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.)?
Emergency Contacts
Primary Emergency Contact Name
*
Primary Emergency Contact Relationship
*
Primary Emergency Contact Phone
*
Secondary Emergency Contact Name
*
Secondary Emergency Contact Relationship
*
Secondary Emergency Contact Phone
*
Primary Insurance Information
Insurance Company Name
*
Subscriber Name
*
Subscriber DOB
*
MM slash DD slash YYYY
ID Number
Group/Policy Number
Customer Service Phone Number
Located on back of insurance card
Secondary Insurance Information
Do you have secondary insurance?
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Yes
No
Insurance Company Name
Subscriber Name
Subscriber DOB
MM slash DD slash YYYY
ID Number
Group/Policy Number
Customer Service Phone Number
Located on back of insurance card
Developmental History
Reason for Referral
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Diagnoses
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Parent/Caregiver Primary Concern(s):
Birth History
Weight
Length
Was your child born prematurely?
Yes
No
If yes, what week was your child born?
Delivery Details (check all that apply)
Spontaneous
Induced
Breech
Normal
Cesarean
Cord around neck
Hemorrhage
Infant injured during delivery
Positive for substances
Post Delivery Period (please complete only if there were delivery complications)
Jaundice
Intensive Care
Cerebral Bleed
Cyanosis (turned blue)
Infection
Other Complications
For "Positive for substances" response, please explain:
For "Infant injured during delivery" response, please explain:
For "Infection" response, please explain:
For "Other Complications" response, please explain:
Early Development (please list all relevant milestones)
Sitting Unsupported
Crawling
Walking
First Word
Toilet Trained
Dress Self
Please list all relevant surgeries:
Background
Previous therapies (please check all that apply)
PT
OT
Speech
Feeding
Vision
Is your child receiving therapy services in school?
Yes
No
If yes, what services?
If yes, what school?
Please list any and all medications your child is currently taking:
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
*
MM slash DD slash YYYY
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
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Parent or Guardian Printed Name
*
Patient Name
*
Date
*
MM slash DD slash YYYY
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
*
MM slash DD slash YYYY
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
*
MM slash DD slash YYYY
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
*
MM slash DD slash YYYY
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:
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Printed Name
*
Date
*
MM slash DD slash YYYY
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.
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