Highest Potential Therapy

Patient Registration Form:

Client's Full Legal Name: *

Address: *

City/State/Zip: *

Gender: *

DOB: *

Age: *

Phone: *

Other Phone:

Mother/Father/Guardian Name: *

DOB: *

Work Phone Number: *

Mother/Father/Guardian Name:

DOB:

Work Phone Number:

Emergency Contact: *

Phone Number: *

Primary Care Physician/Referred By: *

Physician's Phone Number: *

Primary Insurance: *

Phone Number: *

Address: *

Insured: *

Relationship: *

Policy Number: *

Group Number: *

Secondary Insurance:

Phone Number:

Address:

Insured:

Relationship:

Policy Number:

Group Number:

Please list any/all people that you are permitting Highest Potential Therapy, Inc. to discuss and/or view your medical treatment with and their relationship to you. If no name is listed, information will only be discussed with the legal guardian and child.

Check this box if you DO NOT wish to have the patient's medical information discussed with anyone.

The information stated above, to the best of my knowledge, is correct and complete. I authorize Highest Potential Therapy, Inc. *

clear

Relationship: *

Date: *

Liability Release:

Client's Name: *

would like to participate in therapy with Highest Potential Therapy, Inc which may include equine movement as a treatment strategy. I acknowledge the risk and potential for risks of horseback riding. However, I feel that the possible benefits to my son/daughter/, my ward or myself are greater than the risk assumed. I, hereby, intend to be legally bound for myself, my heirs and assigned executers or administrators. I waive and release, forever, all claims for damages against Highest Potential Therapy, Inc. its therapists, volunteers and/or employees for any and all injuries and/or losses, my son/daughter, my ward or I may sustain while participating.

Signature of Client or Parent/Legal Guardian *

clear

Date: *

Photo Release:

I authorize I authorize Highest Potential Therapy Inc. to photograph and/or video for clinical and/or marketing purposes.

I do NOT authorize Highest Potential Therapy Inc. to photograph and/or video for clinical and/or marketing purposes.

Signature of Participant or Legal Guardian: *

clear

Date: *

Cancelation Policy:

In order to achieve desired results, it is essential to participate in treatment consistently. Clients who attend consistently are observed to make better progress. Known cancelations should be made as early as possible, at least 24 hours in advance, via e-mail, telephone or in-person. If on the day of your session, unforeseen events occur, cancellations should be made as soon as possible. If you are experiencing difficulties keeping your appointments, please discuss this with us. We are committed to working with you to determine the best possible schedule for all parties. In the event of repeated cancelations or no-shows, you will be provided with a verbal warning. If the client no-shows or cancels with less than 24 hours notice three or more times, Highest Potential Therapy Inc. serves the right to dismiss the client from services. An average overall attendance rate of at least 75% is required. If the client cancels more than 25% of the time, Highest Potential Therapy Inc. serves the right to dismiss the client from services.

Signature of Participant or Legal Guardian: *

clear

Date: *

HIPAA

Federal law requires that we seek your acknowledgement of receipt of this Notice of Privacy Practices, effective April 14, 2003. Please indicate your acknowledgement with your signature beneath the following statement:

I have received or I have been provided the opportunity to receive a copy of the “Notice of Privacy Practices” that explains when, where and why my confidential health information may be used or shared. I acknowledge that Highest Potential Therapy, Inc. may use and share my confidential health information with others in order to treat me or my child, in order to arrange for payment of my bill and for issues that concern Highest Potential Therapy, Inc.’s operations.

I further acknowledge that I understand that if I have any questions regarding this Notice, or with to file a complaint, I may contact Highest Potential Therapy, Inc.’s Privacy Officer listed below. I also understand that no other staff member, physician or nurse or any other person is authorized to accept a request to exercise my right but the Privacy Office for Highest Potential Therapy, Inc.

Privacy Officer, Highest Potential Therapy, Inc.

PO Box 1035

Minden, NV 89423

Phone: (9160 708-0215

Fax: (775) 301-6143

Signature of Participant or Legal Guardian: *

clear

Date: *

Client's DOB: *

Parent (if applicable): *

Highest Potential Therapy, Inc. is hereby given permission to send reports regarding evaluations and/or treatment to (i.e. doctors, teachers, other therapists, etc.): *

I hereby give permission for information to be released to Highest Potential Therapy Inc. from: *

Signature of Participant or Legal Guardian: *

clear

Date: *

Financial Statement and Policy:

I give permission to receive a therapy evaluation. I understand that enrollment in a treatment program may be recommended.

It is my responsibility to notify Highest Potential Therapy, Inc. prior to any insurance changes even if I have Medicaid coverage, as adding or changing a primary insurance may require prior authorization for services. If prior authorization is not obtained secondary to not notifying Highest Potential Therapy, Inc. about the change in insurance, I will be responsible for services not covered by the insurance (applies to clients covered by Medicaid).

It is my responsibility to notify Highest Potential Therapy, Inc. regarding prior therapy services received as well as future decisions to seek therapy services from other service providers. I understand that seeing multiple providers may affect my insurance coverage, and I will be held responsible for any balance due should billing complications arise (applies to clients covered by Medicaid).

I understand that Highest Potential Therapy, Inc. will honor new Medicaid coverage moving forward from the time a family provides a copy of the insurance card and after prior authorization has been approved by Medicaid. Please note that Highest Potential Therapy, Inc. is unable to bill Medicaid retroactively, even if Medicaid authorizes retroactive billing.

If I am responsible for a full payment or a co-payment amount, I authorize my credit card to be charged the full amount due. Highest Potential Therapy, Inc. will make every effort to give warning that the charge will be made.

I authorize the release of any medical or other information necessary to my insurance company to process claims.

Name on Credit Card: *

Type of Credit Card (i.e. Visa): *

Credit Card Number: *

Expiration Date: *

Zip Code: *

Signature of Participant or Legal Guardian: *

clear

Date: *

Please upload a photo or scan of the front and back of the client's insurance card