Booking - Great Strides Rehab

First Name *

Last Name *

Email *

Gender *MaleFemale

Date of Birth *

Social Security Number:

Address: *

City: *

State: *

Zip: *

Mothers Name: *

Mothers Cell phone number: *

Fathers Name: *

Fathers Cell phone number: *

Who should we contact regarding therapy related information?

MotherFatherOthers

If other please specify

Please upload a copy of the front of your driver's license here.* *

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Who is your childs Primary Care Physician: *

Who referred you to Great Strides Rehabilitation?

Please list any additional authorized parties that will pick up or drop your child off for services ( ie nanny or grandparents) *

If other please specify

Location and Days/Times: *

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

Public/Private SchoolDaycareOtherNone

Location and Days/Times: *

Which location do you want to receive therapy? *

Mandarin - San Jose Blvd.Hope Haven - Beach Blvd.Orange Park - College DriveNew Smyrna Beach - Wallace RoadWorld Golf VillageCallahan - SR 200First Available (Jacksonville area only)

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 PREFERRED schedule for therapy sessions?

What is your current AVAILABILITY for appointment scheduling?

Are there any factors influencing your ability to maintain the same schedule for up to 6 months? I e. changing work schedule, changing school schedule, etc.?

Do you have any requirements for scheduling multiple services such as we must start ABA therapy first before other therapies, we must schedule back to back appointments, etc.?

Please list any diagnosis your child has been given, the date of diagnosis and any relevant details.

Does your child have a behavioral diagnosis such as Autism, ADHD, Oppositional Defiant Disorder, etc.?YesNo

Please describe your top 3 goals for therapy: *

A prescription from your child's primary care physician is required to request services from your insurance carrier. The prescription must contain your child's diagnosis AND the therapy you are looking to begin. Please upload the prescription here. *

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Primary Insurance Company: *

Type of PlanHMOPPOOther

Group Number: *

Member Number: *

Insured Person: *

Insured Date of Birth *

Please upload a copy of the front of your insurance card here. *

No file chosen

Please upload a copy of the back of your insurance card here. *

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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.

Please Initial: *

Date *

Do you have a secondary insurance?YesNo

Secondary Insurance Company

Type of PlanHMOPPOOther

Group Number:

Member Number:

Insured Person:

Insured Date of Birth

Please upload a copy of the front of your insurance card here. *

No file chosen

Please upload a copy of the front of your insurance card here *

No file chosen

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.

Please Initial : *

Date *

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.

Please initial that you have read and understand the Cancellation and tardiness policy: *

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

MotherFatherOther- please list their information below

If other, Please supply their name, address, phone number and email address

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

Parents Signature: *

Date *

I have been provided the HIPAA privacy Policy *

Who should we contact regarding therapy related information?

Which therapy would you like to enroll in? (Please check all that apply) *