REGISTRATION AUTISM TREATMENT SERVICES
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1 559 Zor Shrine Place Madison, WI P: F: wi.com CLIENT INFORMATION (First, MI, Last) (Street, City, State, Zip) REGISTRATION AUTISM TREATMENT SERVICES of Birth Home Phone Gender Social Security # County of Residence PARENT OR GUARDIAN If Client is a minor, please complete parent/guardian information. * need only be completed if different than Client. Parent/Guardian Name Parent/Guardian Name of Birth (Parent/Guardian) Relationship to Client Cell Phone Name of Employer of Employer OR Where Reachable Work Phone address of Birth (Parent/Guardian) Relationship to Client Cell Phone Name of Employer of Employer OR Where Reachable Work Phone address PHYSICIAN OR MEDICAL FACILITY Physician Name Phone Number Fax Number By signing here, I am agreeing that I have received a copy of the Privacy Practice Notice: Signature of Client or Parent/Guardian
2 PATIENT BILL OF RIGHTS WISCONSIN STATE LAW REQUIRES THAT YOU READ AND SIGN THIS FOR OUR RECORDS When you receive services for mental health, alcoholism, drug abuse, or developmental disability as an inpatient or outpatient, you have the following rights under Wisconsin Statute Sec 51.61: Treatment and Related Rights: To be free from having unreasonable arbitrary decisions made about you. To receive prompt and adequate treatment To refuse any treatment To be free from unnecessary or excessive medication Communication and Privacy Rights: To refuse to be filmed or taped without your consent To have your treatment records and conversations about your treatment kept confidential (Sec Stats.) To have access to your treatment record after discharge (or during treatment if the facility director approves it) and to have access at all times to records of medications you take or any treatment you receive for physical health reasons. Right of Access to Courts: To bring legal actions for damages against those who violate your rights. Your Right to Complain: If you feel that your rights have been violated, you have the right to a grievance procedure. Our agency has a grievance process through which you may file your complaint. Grievances must be filed in writing within forty-five days of the incident or issue. The staff will supply you with a copy of the IDS Grievance Procedure upon request. You may, at the end of grievance process, or at any time during it, choose to take the matter to court. of Birth
3 INSURANCE INFORMATION We require a complete copy of your insurance card (front and back) along with this completed form. Please Note: Wisconsin ForwardHealth Medicaid will cover initial intakes (for all diagnoses), diagnostic services (for all diagnoses), and mental health services (for diagnoses other than the autism spectrum), but will not cover any autism treatment services. The only Wisconsin ForwardHealth Medicaid funding source that pays for autism services is the Children s Long-Term Support (CLTS) waiver. Autism services must be listed on the child s IFSP in order for the CLTS waiver to cover them. I do not have insurance benefits to cover the services I will be receiving and agree to pay my bill personally at the time of services. If I am unable to pay in full, I will make payment arrangements with the accounting office. (Please if this applies.) Primary Carrier* Phone Number Policy Holder Policy/Member # Person Code Group # *Please provide copy of the front and back of insurance card Secondary Carrier** Phone Number Policy Holder Policy/Member # Person Code Group # **This includes Medicaid, Title 19, and Katie Beckett Signature on File I authorize use of this signature form on all my insurance submissions. I authorize IDS to release to my insurance company any medical information necessary to process my claims. I understand that I am responsible for my bill. I authorize payment direct to Integrated Development Services, Inc. I permit a copy of this authorization to be used in place of the original. I understand that this consent may be revoked by me at any time, except to the extent that action has already been taken. This consent remains valid unless expressly revoked. I hereby release IDS from and legal responsibility or liability that may arise from the act of filing my insurance claim. I have been advised of the cost of treatment. I understand that if I am receiving ABA therapy, this is NOT a covered benefit through Medical Assistance, and if I do not have other coverage, I will be responsible for the bill. of Birth
4 FINANCIAL AGREEMENT You are responsible for the costs of services provided by Integrated Development Services, Inc. We ask that you pay any expected co-pay/personal fees at the time of each visit. If we underestimate your co-pay, you will be billed at the end of each month, and we ask that you make payment within 30 days. Should you over pay, any payment will be promptly refunded. As a service to our clients insurance claims will be submitted to your insurance carrier(s). If you have HMO coverage and have a current referral, your policy may cover the initial costs if benefits have not already been used elsewhere. If your HMO requires you to have a referral for services provided by our office, it is your responsibility to obtain a referral and keep the referral current. You will personally be responsible for the copay portion of the benefits, for costs incurred during any period in which you do not have a current referral, and for services you receive that are not covered by your HMO. If you have non-hmo insurance, you will be responsible for deductible and co-pay portions. You are responsible for any prior authorizations that may be needed. You are also personally responsible for any costs that exceed the benefit limits of your insurance policy or are not covered by your policy. If you have questions about what your insurance may cover, you should contact your insurance company and check benefits. If you or your child have a Wisconsin ForwardHealth Medicaid plan you are responsible for keeping your ForwardHealth Medicaid coverage current. If you have a lapse in Wisconsin ForwardHealth Medicaid coverage, or coverage is cancelled, you will be responsible for payment of services. We will always bill your private insurance first for services provided. If your insurance will not cover services, we will then bill your Wisconsin ForwardHealth Medicaid plan. Please note that if you have a Wisconsin ForwardHealth Medicaid plan that is managed by a HMO (i.e. DeanCare, Physicians Plus), treatment services through this office are not covered and we cannot provide services to you. The fee for services is as follows: Diagnostic Evaluations Individual Mental Health Treatment Individual ABA Behavioral Treatment $150.00/hour $120.00/hour $60.00/hour Accounts must be kept current and monthly statements must be paid upon receipt unless written arrangements have been made. If your account balance goes above $300, and you have not made payment arrangements with our office, we may ask that you temporarily stop services until your account is brought up to date. For your convenience our office does accept MasterCard and Visa. If you have any questions regarding your account, please ask our account manager. Integrated Development services reserves the right to seek legal means to secure reimbursement. I have read, understand, and agree to the policies described above. I understand that I am responsible for my bill with Integrated Development Services, Inc. regardless if I have insurance coverage or not. of Birth
5 AUTHORIZATION FOR THE RELEASE OF INFORMATION of Birth I, the undersigned, hereby give consent to Integrated Development Services to release to and/or receive my child s records for the purpose of diagnosis and treatment planning from: School County of Residence Private Insurance Physician Other Specific records authorized for release include: Complete medical records IQ scores Medication records Admission history records Complications M-Team/ IEP results Past history records Progress and therapy notes Verbal exchanges Social history records Workshop evaluations Discharge summary Psychological test records Recommendations Diagnosis Psychiatric and psychological evaluations Prognosis Treatment notes and summaries Other (please list): Right to inspect or Copy the Health Information to be Used or Disclosed-I understand that I have the right to inspect or copy the health information I have authorized to be used or disclosed by this authorization form. I may arrange to inspect my health information or obtain copies of my health information by contacting the administrative office. Right to Receive Copy of this authorization-i understand that if I agree to sign this authorization, I have a right to receive a signed copy of the form. Right to Refuse to Sign this authorization-i understand that I am under no obligation to sign this form and that the person(s) and/or organizations listed above who I am authorizing to use and/or disclose my information may not condition treatment or payment on my decision to sign this authorization. Right to Revoke This Authorization-I understand that I may revoke this authorization in writing at any time. To obtain information on how to revoke my authorization or to receive a copy of my revocation, I may contact the administrative office. I am aware that my revocation will not be effective as to uses and/or disclosures of my health information that the person(s) and or organizations listed above have already made in reference to this authorization. Integrated Development Services, Inc. will not condition treatment, payment, enrollment, or eligibility for benefits on whether this form is signed. A photocopy of this authorization is as valid as the original. This authorization is valid for one year from the date signed below. of Birth
6 INFORMED CONSENT FOR TREATMENT I give my permission for this minor to receive the following autism treatment services from Integrated Development Services, Inc. for the purpose of achieving goals as per the treatment plan designed for my child. Alternative treatment models have been explained to me. I have been told about possible outcomes and side effects of treatment recommendations, treatment recommendations and benefits of treatment recommendations, approximate duration and desired outcomes of treatment recommendation in the treatment plan, the rights of a consumer receiving outpatient mental health services, including the rights and responsibilities in the development and implementation of an individual treatment plan, the fees that the consumer or responsible party will be expected to pay for the proposed services, how to use the clinic s grievance procedure under HFS 94, the means by which a consumer can obtain emergency mental health services during periods outside the normal operating hours of the clinic (see emergency procedure), the clinic s discharge policy, which includes the circumstances under which a consumer may be involuntarily discharged for inability to pay or for behavior reasonably the result of mental health symptoms. I agree that this professional may also interview these other persons while preparing my child s treatment plan: see Authorization for Release of Information with parent / legal representative s signature. A report or reports concerning the therapist s findings from an initial assessment will be available no more than three weeks after the Intake Interview. My signature below means that I understand and agree with all of the points above. I understand that this consent is valid for one year from the date listed below at which time new consent will be required. I understand that I have the right to withdraw my consent at any time, in writing. I have read and been give a copy of the client s rights and grievance procedure. of Birth I, the therapist, have discussed the issues above with the minor consumer s parent or legal representative. My observations of this person s behavior and responses give me no reason, in my professional judgment, to believe that this person is not fully competent to give informed and willing consent to the minor consumer s treatment. Therapist Signature Printed Name of Therapist For internal use only Therapist Diagnosis
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