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Gender *

Who should we contact regarding therapy related information?

Parents Current Marital Status: *
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Which therapy would you like to enroll in? (Please check all that apply) *

Is your child receiving services at any other facilities? Check all that apply *

Does your child attend a day program? Check all that apply *

Which location do you want to receive therapy? *

Please understand that therapy openings are often limited. The more flexible you can be about your scheduling availability and requirements the quicker we can get you scheduled.

What is your current AVAILABILITY for appointment scheduling?

9am-12pm
12pm-3pm
3pm-6pm
Does your child have a behavioral diagnosis such as Autism, ADHD, Oppositional Defiant Disorder, etc.?
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Type of Plan
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I authorize Great Strides Rehabilitation to release of any medical or other information to all of my insurance Carriers or other third party payor"s for the processing of claims or other insurance purposes.

Do you have a secondary insurance?
Type of Plan
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We ask that you verify coverages for the services prescribed by your child's pediatrician. You can do that by calling the member service number on the back of the card.
 
All co-pays, co-insurance or deductible payments are due at the time of service.Past due accounts are subject to a 5% late fee effective January 1, 2018.
 
Effective January 1, 2018, Charges over 90 days not reimbursed by your insurance carrier will be invoiced to you.  You will be subject to a filing fee of $85.00 for each claim that has been filed and denied by your insurance company.
 
All accounts are subject to a $5.00 supply charge for supplies and equipment such as toothbrushes, theraputty, modality and infection control supplies, etc. that are not generally reusable and are prepared and used on an individual basis. The cost will be included as a one time charge on your initial visit as permitted by your medical plan.
 
I have read and understand my financial responsibility. I realize and accept responsibility for charges not covered by all of my insurances.
Cancellation Policy & Tardiness
 
Please notify Great Strides Rehabilitation 24 hours in advance if you are unable to keep your scheduled appointment by calling the front desk at 904.886.3228.  
 
For new patients, we are unable to reschedule you if you no show your 1st appointment .
 
For existing patients, If you have (3) three or more cancellations or no shows in a quarter, you will be charged a $50.00 late fee.  In addition, your therapist may discharge your child.
 
In consideration of other patients and staff members, if you are going to be late for your appointment, please call the front desk at 904.886.3228 to ensure your therapist will still be able to see you. Your appointment may need to be rescheduled.
 
All therapists are scheduled with back to back appointments, therefore, If you are late dropping off or picking up your child from therapy, there will be late fee of $1.00 per minute.

Who is the person that will handle the financial responsibilites for this child ? *

I hereby give consent for treatment to be rendered to my child.

Great Strides Rehabilitation | 12276 San Jose Boulevard, Suite 508 | Jacksonville 32223 | 904.886.3228
Please call for further information or to make an appointment. | Hours: 8 am – 6:30 pm, M-F

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