Client Information Form – Medicaid/Soonercare: This form will help process a claim for those that have Insurance and or Medicaid/Soonercare. Please have the Medicaid/Soonercare policy number to complete this form.
Client Information Form – Insurance Only (In-Network) or Self Pay (Not In-Network): This form is for clients that have insurance or that wish to pay for our services completely out of pocket. If you are unsure that your insurance company is not within our network, please contact us.
Authorization to Release an Individuals Health Information (Send): This form authorizes Today’s Therapy Solutions to release an Individuals Health Record
Authorization to Release an Individuals Health Information (Receive): This form authorizes Today’s Therapy Solutions to receive an Individuals Health Record
Consent for Evaluation and/or Treatment: This gives Today’s Therapy Solutions authorization to provide qualified diagnostic procedures, care or treatment to such individual referenced on this form.
Notice of Privacy Practices Consent: This gives Today’s Therapy Solutions consent in that we may use or share health record information.
Notice of Privacy Practices (TTS): This notice describes how medical information about a client may be used and disclosed by and how you can get access to this information. PLEASE READ THIS NOTICE CAREFULLY.
