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Policy Holder Date of Birth
Relationship to Patient (e.g. Parent, Guardian, other)
Does this child have NJ Family Care or Medicaid as a primary or secondary form of insurance
If no, are you authorized to work in U.S ?yesno
Secondary Insurance Please use this field only if applicable.
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.
Autism DIAGNOSIS Report (IEP is not accepted by Insurance) Please upload a copy of your Autism DIAGNOSIS or IEP
Relationship to Patient Please describe the Emergency Contacts relationship to the Patient (e.g. Parent, Guardian, other)
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
Signature
Signature Date
Relationship to Patient Please complete it if the Patient is unable to sign.
Please be sure your insurance card is included or your insurance information is filled out before clicking SUBMIT below