Referral & Consent Form

REFERRAL FORM is needed PRIOR to scheduling.
Please include if available:
• Copy of Insurance card(s)
• Client’s completed CCA
• Consent and Release (can be signed in office if legal guardian is present at appointment).

Client Information:

Name: , Gender: Client phone: Age: DOB:
Street Address: City: State: Zip:

Name of Person Signing:

Can messages be left on answering machine?
Can we text for scheduling purposes?

Parent/Caretaker Info (if applicable):

Name:
Contact Number:
Email Address :
Street Address:       City:        State:      Zip:

Legal Guardian Info (if applicable):

Name:
Contact Number:
Email Address :
Street Address:       City:        State:       Zip:

Referral Agent (if applicable):

Agent Name:      Agency:      Relationship to Client:
Street Address:       City:   State:   Zip:
Contact Number:       Fax Number:       Email Address:
Send Completed Report By:

Insurance Information:

BOTH MEDICAID AND OTHER INSURANCE MUST BE LISTED. We do not
accept Medicare. Please call office to check on other insurance.

Self Pay?

Insurance Providers:

Medicaid/Health Choice:

Medicaid/Health Choice Number: County:

Blue Cross / Blue Shield:

Policy Number: Name of Cardholder:

Client's Relationship to Policy Holder:

Other Insurance:

Provider: Policy Number: Group Number: _ Policy Holder: Policy Holder's DOB: Client's Relationship to Policy Holder: Insurance Provider's Phone Number:

Copy of Insurance Documents:

Additional Information:

Is this assessment court ordered?
Client’s Current Diagnosis:
Current Medication(s):
Prescribing Doctor:   Prescribing Doctor's Office Number:

In order insurances to reimburse providers for Psychological Testing, the testing must be
Medically Necessary. Medical Necessity is defined as; a service which in the opinion of the
primary service provider is reasonably needed to prevent the worsening of a condition, to
establish a diagnosis and/or to assist the covered individual to achieve maximum functional
capacity. PLEASE CLEARLY DEFINE THE MEDICALLY NECESSARY REASONS
FOR THIS INDIVIDUAL TO RECEIVE TESTING. Additionally, list current concerns and
goals for this assessment. Please be as thorough as possible.

Testing Type:

If Other Please Describe:

CURRENT SERVICES :

If Other Please Describe:

PROVIDERS:

HISTORY:

If Other Please Describe:

Copies of Prior Assessments (if applicable):

Lawful and Truthful Submission

I hereby confirm that all information contained within this document are factual and accurate to the best of my knowledge.

Client Consent:

You indicated that you are the legal guardian of the client and/or are legally deemed capable of
signing for consent.

Relationship to Client:

I hereby consent to assessment services provided by the Grandis Evaluation Center, PC. I understand
that I may refuse any or all services at anytime. Services may include, but are not limited to
developmental, mental health, behavior, cognitive, achievement, adaptive and personality assessment,
consultation and/or outpatient therapy. I understand that a written report will be generated from an
assessment and this report will be sent to the referring agency given the proper release of Protected
Health Information is in order. I understand that requests by the undersigned to inspect the report or
receive a paper copy of this report will be made through the referral source. If I am involved in a court
proceeding and a request is made for information about professional services covered under this
consent, such information is considered privileged and cannot be disclosed without further
authorization. This privileged does not apply if I am being evaluated for a 3rd party or the evaluation is
court ordered. (In the case of an emergency I give permission to obtain any emergency services
required. I understand that I will be financially responsible for such care).

Client/Legally Responsible Person's Initials: Date:

Client Rights: I have received and read a copy of the Professional Services Agreement from the
Grandis Evaluation Center, PC. I understand its content regarding Client’s Rights and Responsibilities
and my questions about this Professional Services Agreement have been answered.

Client/Legally Responsible Person's Initials: Date:

HIPAA Notice of Receipt of Privacy Practices
• I acknowledge that I have received and read a copy of the Notice of Privacy Practices for services
provided by the Grandis Evaluation Center, PC.
• I understand that the Notice of Privacy Practices discusses how my protected health information (PHI)
may be used and/or disclosed and my rights with respect to my PHI.
• I may obtain an additional copy of this Notice at any time. I understand that the terms of this Notice
may be changed in the future and I may request a copy of the new Notice.

Client/Legally Responsible Person's Initials: Date:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

March 28, 2018 7:03 pm EDT

Referral & Consent Form Uploaded by Mike Grandis - info@gectesting.com IP 66.112.164.80