Client Enrollment Packet

Patient's Name*
First Last
Patient's Nickname
First Last
Patient's Date of Birth*
Month
Day
Year
Patient's Primary Residence*
Street Address Address Line 2 City State ZIP Code
Number of Siblings in home:
Ages of Siblings:

Parent/Guardian Information
Parent/Guardian's Name*
First Last
Relationship to Patient*
Does this Parent/Guardian have legal decison making authority?*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Enter Email Confirm Email
Parent/Guardian Information
Parent/Guardian's Name
First Last
Relationship to Patient
Does this Parent/Guardian have legal decison making authority?*
Address
Street Address Address Line 2 City State ZIP Code
Phone
Email
Enter Email Confirm Email

Emergency Contact Information
Please list Emergency Contacts other than the Parent/Guardian.
Emergency Contact Name*
First Last
Emergency Contact Phone*
Relationship to Patient*

Educational Information
Name of School*
School Address*
Street Address Address Line 2 City State ZIP Code
Teacher Name*
First Last
School Phone*
Teacher's Email
School Schedule*
Please indicate the times your child is in attendance (ie. Monday 8am-12pm)

Medical Considerations
Primary Diagnosis*
Secondary Diagnosis
Doctor's Name*
First Last
Doctor's Phone*
Medical Concerns
Reportable Communicable Diseases (press and hold shift to select multiple)*
Please indicate if any of the following are current or previous conditions.
Please list medications the patient takes
Please list any dietary restrictions
Please list any allergies
Any other medical concerns or comments

Consent for Emergency Medical Treatment
As the parent or authorized representative, I hereby give consent to Montessori Autism Programs and Services to obtain all emergency medical or dental care prescribed by a duly licensed physician (M.D./D.O.) for my child. This care may be given under whatever conditions are necessary to preserve the life, limb, or well being of my child.
Patient's Name*
Parent or Guardian Name*
First Last
Relationship to Patient*
Signature*
Today's Date*
MM slash DD slash YYYY

Patient's Range of Services
Please select any services the patient receives:
- Speech and Language Pathology
- Occupational Therapy
- Functional/Adaptive Behavior Therapy
- Other
Range of Services Information
If the patient receives services, please list the schedule, location and provider information for each service received.

Individuals Authorized for Pick Up
Please list individuals that are authorized to pick up the patient from MAPS programs.
Name
First Last
Phone
Relationship to Patient
Name
First Last
Phone
Relationship to Patient
Name
First Last
Phone
Relationship to Patient
Signature
By signing below, I acknowledge that individuals listed above have my permission to pick up the patient from MAPS programs.
Signature*
Parent/Guardian Name*
First Last
Today's Date*
MM slash DD slash YYYY

MAPS Observation Consent Form
School Phone Number*
Principal's Name*
First Last
Principal's Email
Teacher's Name*
First Last
Teacher's Email
Student's Name*
First Last
Student's Date of Birth*
MM slash DD slash YYYY
Parent/Guardian Signature*
I hereby consent to MAPS conducting observations of the above named student.
Parent/Guardian Name*
First Last
Today's Date*
MM slash DD slash YYYY

Patient Financial Repsonsibility
Patient's Name*
First Last
Authorization to Pay Claims to MAPS
I authorize payment from my insurance company to be directly sent to MAPS. This allows MAPS to file claims on my behalf.
Financial Responsibility
I UNDERSTAND I MUST DISCLOSE ALL PRIMARY AND SECONDARY INSURANCE AND NOTIFY MAPS IMMEDIATELY OF ANY INSURANCE CHANGES. I understand that MAPS will make all reasonable attempts to bill my insurance company first, and will work with me to address potential problems. However, in the event that my insurance company doesn't pay for any portion of services provided, I agree and acknowledge that I am responsible for any fees remaining.
Copayment/Insurance Benefits Knowledge
I understand that it is ultimately my responsibility to inform myself of my insurance benefits and limitations. As a courtesy, MAPS will attempt to verify your insurance benefits and relevant co-pay/deductible amounts. This is an estimate provided by your insurance company to us. It is only upon claim submission and processing (which can take up to 90 days or more) that we are informed by your insurance company of the actual portion you owe of your treatment cost.
Medi-Cal Responsibility
For patients with Medi-Cal coverage: I understand that each month MAPS is required to verify my child's Medi-Cal eligibility for services for the coming month. If MAPS is informed that your child's services will not be funded by Medi-Cal and you do not choose to pay privately, your child's program will be put on hold. We will allow a two-week grace period for you to restore your child's eligibility and then we will have no choice but to place your child's program on hold. Upon request, we will place your child's name on the top of the waiting list for services after the two-week grace period has elapsed. The agreements and obligations that you have with Medi-Cal are confidential and MAPS is not able to assist you in the process of fulfilling these obligations.
Parent/Guardian Signature*
Parent/Guardian Name*
First Last
Today's Date*
MM slash DD slash YYYY

Authorization for MAPS to Use/Disclose Protected Health Information
I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure and no longer be protected under federal law. However, I also understand that federal or state law may restrict redisclosure of drug/alcohol diagnosis, treatment or referral information, mental health information and genetic testing information. Refusal to sign the authorization will not adversely affect your ability to receive health care services or reimbursement for services. The only circumstance when refusal to sign means you will not receive healthcare service is if the health care services are solely for the purpose of providing health information to someone else and the authorization is necessary to make that disclosure. You may revoke this authorization in writing at anytime. If you revoke your authorization, the information described above may no longer be used or disclosed for the purposes described in this authorization. Any use or disclosure already made with your permission cannot be undone. To revoke this authorization, please send a written statement to MAPS, Intake Department at 1106 Windfield Way El Dorado Hills, Ca 95762 and state that you are revoking this authorization. To revoke this authorization orally, please contact MAPS Intake Department at (916) 357-5837 and state that you are orally revoking this authorization. By signing below, I acknowledge that I have read and understood this authorization. Unless revoked, this authorization expires in 12 months.
Parent/Guardian Signature*
Parent/Guardian's Name*
First Last
Today's Date*
MM slash DD slash YYYY
Patient's Name*
First Last

Consent to Treat
Consent
I, the parent or legal guardian, hereby consent to medical care for the welfare of my child while said child is under the care of MAPS; Montessori Autism Programs and Services, Inc.
Client's Name*
First Last
Signature
Parent or Legal Guardian's Name*
First Last
Date*
MM slash DD slash YYYY

None
Acquired Immune Deficiency Syndrome (AIDS)
Amebiasis
Anaplasmosis/Ehrlichiosis
Anthrax, human or animal
Babesiosis
Botulism (infant, foodborne, wound, other)
Brucellosis, animal
Campylobacteriosis
Chancroid
Chickenpox (Varicella)
Clamydia trachomatis infections
Cholera
Ciguatera Fish Poisoning
Coccidioidomyscosis
Creutzfeldt-Jakob Disease (CJD) and other Transmissible Spongiform Encephalopathies (TSE)
Crypotosporidiosis
Cyclosporiasis
Cysticercosis or taeniasis
Dengue
Diptheria
Domoic Acid Poisoning (Amnesic Shellfish Poisoning)
Encephalitis
Escherichia coli: siga toxin producing (STEC)
Foodborne Disease
Giardiasis
Gonococcal Infections
Haemophilius influenzae, invasive diesease
Hantavirus infections
Hemolytic Uremic Syndrome
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E
Influenza, novel strains
Legionellosis
Leprosy
Leptospirosis
Listeriosis
Lyme Disease
Malaria
Measles (Rubeola)
Meningitis
Meningococcal Infections
Mumps
Parlytic Shellfish Poisoning
Pelvic Inflammatory Disease (PID)
Pertussis (Whooping Cough)
Plague, human or animal
Poliovirus Infection
Psittacosis
Rabies, human or animal
Relapsing Fever
Rickettsial Disease
Rocky Mountain Spotted Fever
Rubella (German Measles)
Salmonellosis
Scombroid Fish Poisoning
Severe Acute Respiratory Syndrome (SARS)
Shiga toxin (detected in feces)
Shigellosis
Smallpox (Variola)
Streptococcal Infections
Syphilis
Tetanus
Toxic Shock Syndrome
Tichinosis
Tuberculosis
Tularemia, animal
Typhoid Fever
Vibrio Infections
Viral Hemorrhagic Fevers, human or animal
West Nile Virus
Yellow Fever
Yersiniosis
Occurence of ANY unusual disease
Outbreaks of ANY disease (not listed)

Client Enrollment Packet

Step 1 of 12 - General Information

Parent/Guardian Information

Parent/Guardian Information

Emergency Contact Information

Educational Information

Medical Considerations

Consent for Emergency Medical Treatment

Patient's Range of Services

Individuals Authorized for Pick Up

Signature

MAPS Observation Consent Form

Patient Financial Repsonsibility

Authorization to Pay Claims to MAPS

Financial Responsibility

Copayment/Insurance Benefits Knowledge

Medi-Cal Responsibility

Authorization for MAPS to Use/Disclose Protected Health Information

Consent to Treat