Complete Your Intake Form Online | Rainbow Therapy Therapy

language

"*" indicates required fields

Patient Information

Name

First Last

Parent or Legal Guardian Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How did you hear about us?*

Preferred language during service

Voorkeurtaal tydens sessie
Թարգմանության ծառայությունները մատուցվում են ըստ, պահանջի
Idioma preferido durante a sessão

Preferred language during service

English, Spanish, Afrikaan, Armenian, Portuguese, any other language

Are you interested in our NJ ABA clinic ages 1 to 5?*

Yes

Daycare Information (if applicable)

Daycare Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Information

Primary Phone*

Secondary Phone

Date of Birth*

MM slash DD slash YYYY

Email*

Ethnicity

Gender

Male

Female

Non-Binary

Days and Hours Desired for ABA Services

Mondays*

Available

Not Available

Monday Start Time

Monday End Time

Tuesdays*

Available

Not Available

Tuesday Start Time

Tuesday End Time

Wednesdays*

Available

Not Available

Wednesday Start Time

Wednesday End Time

Thursdays*

Available

Not Available

Thursday Start Time

Thursday End Time

Fridays*

Available

Not Available

Friday Start Time

Friday End Time

Saturdays*

Available

Not Available

Saturday Start Time

Saturday End Time

Sundays*

Available

Not Available

Sunday Start Time

Sunday End Time

Total Weekly Hours ABA Service Desired*

Note about Days + Hours Desired for ABA Services

Insurance Information

Primary Insurance*

Subscriber ID

Group

Name of Insured | Policy Holder*

First Last

Policy Holder Date of Birth*

MM slash DD slash YYYY

Relationship to Patient Please describe the Insured's relationship to the Patient (e.g. Parent, Guardian, other)

Relationship to Patient

Does this child have NJ Family Care or Medicaid as a primary or secondary form of insurance*

Yes

Secondary Insurance Please use this field only if applicable.

Secondary Insurance

Subscriber ID (Secondary)

Group

Insurance Card | FRONT Please upload an image of the FRONT of your Insurance Card.*

Insurance Card | BACK Please upload an image of the BACK of your Insurance Card.*

Insurance Card | FRONT*

Drop files here or

Max. file size: 50 MB.

Insurance Card | BACK*

Drop files here or

Max. file size: 50 MB.

Autism DIAGNOSIS Report (IEP is not accepted by Insurance) Please upload a copy of your Autism DIAGNOSIS or IEP *

Autism DIAGNOSIS Report (IEP is not accepted by Insurance)*

Drop files here or

Max. file size: 50 MB.

Emergency Contact Information

Name*

First Last

Phone*

Relationship to Patient

Relationship to Patient
Please describe Emergency Contacts relationship to the Patient (e.g. Parent, Guardian, other)

HIPAA Acknowledgement

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health insurance portability and Accountability Act of 1996 (HIPAA).

I understand that by signing this consent I authorize Rainbow ABA to use and disclose my protected health information to carry out:

• Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)

• Obtaining payment from third-party payers (e.g. my insurance company)

• The day-to-day healthcare operations of Rainbow ABA.

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA.

I understand that you reserve the right to change the terms of this notice from time to time and that I may contact Rainbow ABA at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

Patient Name*

First Last

Signature*

Signature Date*

MM slash DD slash YYYY

Relationship to Patient Please complete if Patient is unable to sign.

Relationship to Patient

Please be sure your insurance card is included or your insurance information is filled out before clicking SUBMIT below

"*" indicates required fields

Información del paciente

Nombre

First Last

Parent or Legal Guardian Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How did you hear about us?*

Preferred language during service Voorkeurtaal tydens sessie Թարգմանության ծառայությունները մատուցվում են ըստ, պահանջի Idioma preferido durante a sessão English, Spanish, Afrikaan, Armenian, Portuguese, any other language

Preferred language during service

Are you interested in our NJ ABA clinic ages 1 to 5?*

Yes

Información de guardería (si corresponde)

Nombre de la guardería

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Información del contacto

Teléfono Principal*

Teléfono secundario

Date of Birth*

MM slash DD slash YYYY

Correo electrónico*

Etnicidad

Gender

masculino

femenino

No binario

Days and Hours Desired for ABA Services

Mondays*

Available

Not Available

Monday Start Time

Monday End Time

Tuesdays*

Available

Not Available

Tuesday Start Time

Tuesday End Time

Wednesdays*

Available

Not Available

Wednesday Start Time

Wednesday End Time

Thursdays*

Available

Not Available

Thursday Start Time

Thursday End Time

Fridays*

Available

Not Available

Friday Start Time

Friday End Time

Saturdays*

Available

Not Available

Saturday Start Time

Saturday End Time

Sundays*

Available

Not Available

Sunday Start Time

Sunday End Time

Total Weekly Hours ABA Service Desired*

Note about Days + Hours Desired for ABA Services

Información del seguro

Seguro primario | Otro (no listado)*

Subscriber ID

Group

Nombre del asegurado | Titular de la póliza*

First Last

Policy Holder Date of Birth*

MM slash DD slash YYYY

Relación con el paciente Describa la relación del asegurado con el paciente (por ejemplo, padre, tutor, otro)

Relationship to Patient

Does this child have NJ Family Care or Medicaid as a primary or secondary form of insurance*

Yes

Seguro secundario Please use this field only if applicable.

Secondary Insurance

ID de suscriptor (secundario)

Group

Tarjeta de seguro | PARTE DELANTERA Please upload an image of the FRONT of your Insurance Card.

Tarjeta de seguro | ESPALDA Please upload an image of the BACK of your Insurance Card.

Tarjeta de seguro | PARTE DELANTERA*

Drop files here or

Max. file size: 50 MB.

Tarjeta de seguro | ESPALDA*

Drop files here or

Max. file size: 50 MB.

DIAGNÓSTICO del autismo Please upload a copy of your Autism DIAGNOSIS or IEP

DIAGNÓSTICO del autismo*

Drop files here or

Max. file size: 50 MB.

Información de Contacto en caso de Emergencia

Nombre*

First Last

Teléfono*

Relationship to Patient

Relación con el paciente
Please describe Emergency Contacts relationship to the Patient (e.g. Parent, Guardian, other)

Reconocimiento de HIPAA

Entiendo que tengo ciertos derechos a la privacidad con respecto a mi información médica protegida. Estos derechos me son otorgados bajo la Ley de Responsabilidad y Portabilidad de Seguros de Salud de 1996 (HIPAA).

Entiendo que al firmar este consentimiento autorizo a Rainbow ABA a usar y divulgar mi información médica protegida para llevar a cabo:

• Tratamiento (incluido el tratamiento directo o indirecto de otros proveedores de atención médica involucrados en mi tratamiento);

• Obtener el pago de terceros pagadores (por ejemplo, mi compañía de seguros);

• El% MI% al% MI% de las operaciones de salud diarias de Rainbow ABA.

También se me ha informado y se me ha otorgado el derecho de revisar y obtener una copia de su Aviso de prácticas de privacidad, que contiene una descripción más completa de los usos y divulgaciones de mi información médica protegida y mis derechos según la HIPAA.

Entiendo que se reserva el derecho de cambiar los términos de este aviso de vez en cuando y que puedo comunicarme con Rainbow ABA en cualquier momento para obtener la copia más actualizada de este aviso.

Entiendo que tengo derecho a solicitar restricciones sobre cómo se usa y divulga mi información médica protegida para llevar a cabo operaciones de tratamiento, pago y atención médica, pero que usted no está obligado a aceptar estas restricciones solicitadas. Sin embargo, si está de acuerdo, está obligado a cumplir con esta restricción.

Entiendo que puedo revocar este consentimiento, por escrito, en cualquier momento. Sin embargo, cualquier uso o divulgación que haya ocurrido antes de la fecha en que revoque este consentimiento no se verá afectado.

Nombre del paciente*

First Last

Firma*

Fecha de firma*

MM slash DD slash YYYY

Relación con el paciente Please complete if Patient is unable to sign.

Relationship to Patient

Asegúrese de que su tarjeta de seguro esté incluida o de que la información de su seguro esté completa antes de hacer clic en ENVIAR a continuación.

Intake Form

language:

language

Patient Information

Preferred language during service

Daycare Information (if applicable)

Contact Information

Days and Hours Desired for ABA Services

Insurance Information

Emergency Contact Information

HIPAA Acknowledgement

Información del paciente

Información de guardería (si corresponde)

Información del contacto

Days and Hours Desired for ABA Services

Información del seguro

Información de Contacto en caso de Emergencia

Reconocimiento de HIPAA

Translation Services Available | Услуги перевода доступны | Servicios de traducción disponibles | Services de traduction disponibles

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Contact Us

Apply for Services

Intake Form

language:

language

Patient Information

Preferred language during service

Daycare Information (if applicable)

Contact Information

Days and Hours Desired for ABA Services

Insurance Information

Emergency Contact Information

HIPAA Acknowledgement

Información del paciente

Información de guardería (si corresponde)

Información del contacto

Days and Hours Desired for ABA Services

Información del seguro

Información de Contacto en caso de Emergencia

Reconocimiento de HIPAA

Translation Services Available | Услуги перевода доступны | Servicios de traducción disponibles | Services de traduction disponibles

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