Patient Information Questionnaire & Release of Information Form

/Patient Information Questionnaire & Release of Information Form
Patient Information Questionnaire & Release of Information Form2018-08-20T18:58:11+00:00

Patient Information Questionnaire & Release of Information Form

FULL SPECTRUM BEHAVIOR ANALYSIS, LLC Patient Information Questionnaire
  • After completing both forms (Patient Information & Release of Information) are completed, please send to our staff by clicking on the SEND buttons below
  • Insurance Information

    Primary Insurance Information (United Healthcare, Cigna, Aetna, etc.) if no Medicaid coverage.
  • EMERGENCY CONTACT

    (Parent/Guardian if patient is a minor)
  • RELEASE OF INFORMATION

    This authorizes the release or ability to obtain protected health information concerning the above named client.Health information may relate to my past, present or future physical or mental health condition, and the provision of my health care, or payment for my health care services. This information may be disclosed to or obtained from the following:
  • OR
  • Required Documents

    Thank you for your interest in ABA services with Full Spectrum Behavior Analysis. To complete your application, please attach the documents below or send copies of the following to one of the following destinations: Email: newclients@fullspectrumaba.com Fax: (813) 920-9252 Mail: 16414 Lake Church Drive, Odessa, Fl 33556
  • Required Documents

    Thank you for your interest in ABA services with Full Spectrum Behavior Analysis. To complete your application, please send copies of the following to one of the following destinations: Email: fsbaintake@fullspectrumaba.com Fax: (813) 920-9252 Mail: 16414 Lake Church Dr, Odessa, FL 33556
  • Drop files here or
  • Drop files here or
    This document must include: a) Patient Name b) Patient Date of Birth c) “ABA therapy, evaluation and treatment” d) Specific ICD10 diagnosis code(s). Cannot be an “unspecified” code. For example, F90.9 ADHD UNSPECIFIED is not accepted. e) Must be signed by an MD or DO. Signatures from an ARNP or PA-C are not accepted. f) Physician’s name g) Referring physician must be a Medicaid provider.
  • Drop files here or
    The Comprehensive Diagnostic Report is an evaluation of the child’s cognitive and developmental functioning resulting in the child’s diagnosis, and is often performed by a neurologist, psychiatric, neuropsychologist, or medical doctor. You may have a copy of this report in your child’s records, or you may have to obtain a copy from the diagnosing professional. Depending on the child’s diagnosis, the report may involve information about the child’s history, parent or teacher interviews, behavioral observations, speech or language assessments, medical evaluations, genetic testing, or standardized cognitive assessments.
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