MUSIC. HEALTHCARE. PERFECT HARMONY

The entire staff at The George Center for Music Therapy, Inc. would like to thank you for choosing us and welcome you to our family.  

It is our goal at The George Center to provide you with outstanding services, support, and communication regarding the needs of you or your loved one.  We provide an environment that is encouraging, well-informed, enjoyable, and sincere.  We want you to be an integral and active participant in therapy and learn how to provide an environment that will support your therapeutic progress.  We also want you to be involved in establishing goals, treatment planning, home exercises, and discharge planning.  Our intention is to move towards a level of independence within everyone’s abilities.

Included in our paperwork you will find:

Family/patient information sheet
Consent to treat/ Financial agreement/attendance policy
medical release/permission for exchange of info
Permission to leave site
Audio/visual/student observer release
HIPAA policy

Please read all forms thoroughly so that you are informed about the agreements you are signing, and ask any questions to better help us serve you and your family.  

If we are billing insurance, some other pieces of information are requested:
Copy of driver’s license
Copy of the front and back of your insurance card
Current prescription from PCP – Must state MT services 1x a week, for 12 months for specific diagnoses
Most recent OT/ST/PT/Psychological/BIP or other relevant
evaluations within the past year

Waiver and/or Grant information (if applicable)

Please note that these items MUST be received prior to your initial evaluation. If they are not received prior to your first appointment, we ask that you arrive 30 minutes early in order to complete your paperwork. This information can be dropped off, faxed to 678-461-8530, or emailed to Jeannie@TheGeorgeCenter.com.

We look forward to working with you!

The George Center for Music Therapy Team

12060 Etris Rd., Suite 200
Roswell, GA  30075
678-701-1203

Members of the North Fulton Wellness Alliance
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PERSONAL INFORMATION & BACKGROUND

 
Information can be shared with:


 
Patient's Name (as it appears on insurance card): *

 
Patient's Gender:


 
Patient's Date of Birth: *

 
Patient's Legal Guardian (if applicable):

 
Address, City, State & Zip Code: *

 
Preferred Phone Number: *

 
Preferred Email: *

 
Patient's Marital Status:


 
Diagnosis: *

 
Primary Physician Name, Address and Phone #:

 
Please list other physicians and specialists involved in patient's care (please list name, specialty and phone number):

 
INSURANCE AND/OR OTHER FUNDING INFORMATION

 
Would you like for us to inquire into potential music therapy coverage with your insurance company?


*

     
 
Insurance Company Name:

 
Member ID #:


 
ICD 10 Diagnosis Code, if known:

 
Name Of Insured:

 
Company Name:

 
Group #:

 
Insurance Claims Address & Phone #:

 
Are there any other therapists billing this insurance policy?

     
 
Have you been approved for the Georgia COMP Waiver? If so, would you like for us to bill your fiscal agent for your music therapy services?

     
 
Is there another source of funding that will be covering music therapy services? Please list all contact information and any special instructions:

 
How did you hear about The George Center for Music Therapy?

 
What are your priorities in coming to The George Center?

 
What are your favorite leisure activities or hobbies?

 
What type of music do you prefer?

 
Are their any particular artists that you are interested in?

 
Have you had music lessons or music therapy services elsewhere?

     
 
Do you have an interest in a particular instrument or have you have experience with an instrument?

 
FAMILY HISTORY

 
With whom do you reside?


 
Is there any information regarding your family situation that we should know?

 
MEDICAL HISTORY

 
Please list any recent hospitalizations:

 
Current medications (Please list dosage, frequency & reason for each medication):

 
Any known allergies? *

     
 
If yes, please list type and expected reaction and rescue medication protocol.

 
Are you fully ambulatory? *

     
 
Do you require any physical assistance or use assistive equipment? i.e. wheelchair, walker, etc... *

     
 
If yes, please indicate:

 
What typically calms/soothes you? *

 
Are you able to communicate verbally? *

     
 
If no, what is your preferred mode of communication? i.e. PIX, ASL, etc...

 
Are their any medical/behavioral issues that we need to be aware of? i.e., seizures, biting or self-injurious behaviors

 
Have you experienced any recent trauma or change in life circumstances? If so, please describe:

 
Is there anything we should know about your gross motor, fine motor, sensory, expressive language or social/emotional needs? If so, please describe:

 
EDUCATIONAL/COMMUNITY INVOLVEMENT

 
Are you currently enrolled in school or support service?

     
 
If yes, please indicate where and what days you attend:

 
Do you currently receive services through school or  a support service?

     
 
If yes, please indicate which services:

 
Are you enrolled in any community activities? If so, please describe.

 
CONSENT TO TREAT

This Consent to Treat Agreement is between The George Center for Music Therapy, Inc., and {{answer_6924131}}, the parent/legal guardian of {{answer_6924063}}.  I, {{answer_6924131}} do consent for The George Center for Music Therapy, Inc. to provide {{answer_6924063}},  with Music Therapy services.  I consent to care and treatment falling under the practice guideline of the American Music Therapy Association (AMTA), and the State of Georgia.  I acknowledge that there is always a risk of injury with any therapy involving physical activities.
This agreement constitutes the entire agreement between the parties regarding the matters contained herein.  This agreement may be signed electronically, in counterparts, each of which shall be deemed an original but all of which together shall constitute one and the same instrument. {{answer_6924131}} understand and agree that they are jointly and severally liable to The George Center for Music Therapy, Inc. with regard to all obligations contained within this agreement. *

     
 
FINANCIAL AND INSURANCE POLICY

We thank you for choosing us as your music therapy provider. We are committed to your treatment being successful. The following is a statement of our financial policy that we would like for you to read carefully read and agree to as evidence of your understanding prior to any treatments. 

We must emphasize that our relationship is with you, not your insurance company. We file the insurance claim as a courtesy to our patient's . All charges are ultimately your responsibility from the date services are rendered. Our service is not always a covered benefit in all contracts. It is important that you read and understand YOUR health insurance policy and it's requirements for coverage. We are not responsible for knowing the requirements of your plan. 

Benefits will be verified upon receipt of your insurance information. You will be made aware of any estimated out-of-pocket expenses prior to the start of services. Information obtained from insurance companies is not always a guarantee of payment. We strive to keep open communication in regards to insurance payment, but it is also important that you review your Explanation of Benefits related to the coverage of our ongoing services as well.

Families will inform The George Center for Music Therapy, Inc. of any changes regarding insurance. Families assign benefits for filed claims to be paid to The George Center for Music Therapy, Inc. Any payment sent directly to the family, intended to cover therapy services provided by The George Center for Music Therapy, Inc., should be given to the front office.

I understand and agree with the above statement:

*

     
 
The usual and customary rate for services is billed to insurance. If we bill your insurance and you have a deductible, the full amount applied to your deductible will be billed to you. The George Center for Music Therapy, Inc. does not accept Medicaid, therefore families are responsible for all co-pays, coinsurances, and deductible expenses associated with each date of service. Please contact us directly if you are experiencing financial hardship. The George Center for Music Therapy, Inc. accepts cash, check, VISA, MASTERCARD, Discover, and American Express.  There is a $50 fee for all returned checks.  

I understand and agree with the above statement. *

     
 
We submit claims to insurance within one month of service dates. If payment has not been received within 60 days, the family/patient will be responsible for the balance. If insurance makes payment, the family/patient will be reimbursed any money that was paid for these services.   If a family/patient receives a bill that is not paid within 30 days of receipt of invoice, there will be a $20.00 late fee added, and services risk being put on hold.

I understand and agree with the above statement. *

     
 
The George Center for Music Therapy, Inc. will file all insurance claims as an out-of-network provider.  Deeming Waiver and SSI Medicaid are not accepted.  We are not contracted with CMO plans (Amerigroup, Peachstate, or Wellcare). If authorization is required, therapists will submit based on need.  Services will be administered after approval has been obtained. The George Center for Music Therapy, Inc. accepts the Georgia NOW/COMP waiver; however, pre-authorization must be approved.

I understand and agree with the above statement. *

     
 
An initial evaluation for music therapy services is $150/hour. Evaluations are an out-of-pocket expense expected at the time of service. An initial evaluation will be needed for all patients starting therapy with our facility. Most evaluations will last 1 hour. If a patient needs a re-evaluation for insurance or personal reasons, the rate will be $150/hr.  Financial arrangements will be made prior to the time of evaluation.

I understand and agree with the above statement. *

     
 
PERMISSION FOR EXCHANGE OF INFORMATION
I authorize The George Center for Music Therapy, Inc. to release necessary and pertinent medical information to physicians, case managers, and insurance companies as needed.

Approved information includes written documents and/or verbal discussion.
*

     
 
Approved information may be exchanged with the following people directly related to my care: *


 
Please list names and phone numbers of approved providers/school:

 
ATTENDANCE POLICY:  

Because of frequent no-shows and cancellations, The George Center for Music Therapy, Inc. has a policy that states that we require a 24-hour notice for cancellations.  After a one-time occurrence, a $40 fee will be charged for EACH missed therapy appointment.   We know that sickness occurs; therefore, if you think that you are sick the night before, please call us and give us notice so we may plan accordingly, and/or contact a family who is on stand by for a make-up session or on a waiting list for an evaluation or services.  

To that end, we require that a current credit card be placed on file at all times. That form will be given to you at your first appointment.  We will run the no-show/last minute cancellation fee on the date of expected service. This ensures that our clinicians will still receive payment in full for their time and service in preparation for the missed therapy session. In the event of a cancellation, we will make every effort to reschedule, as we want you to benefit from therapy.   

If you miss 3 consecutive weeks of therapy, we will make every attempt to hold that slot, but cannot guarantee this with an extended absence.  

The staff at The George Center for Music Therapy, Inc. strives to meet the scheduling needs of every client.  If your therapy time does not work for you, please let us know.  The Board of Health considers the following signs to indicate communicable disease/illness:  vomiting, fever over 100 degrees, diarrhea, sore throat, rash/swelling, red or running nose.  Please be sure you are symptom free for 24-hours before resuming therapy. Please note that if you arrive at therapy exhibiting any of the above symptoms, it is at the therapist’s discretion to send you home in order to protect themselves and our other clients from infectious illness.  

I understand and agree with the above statement. *

     
 
PERMISSION FOR PARENT TO LEAVE SITE DURING TREATMENT (if applicable):

I, {{answer_7123336}} , understand that while {{answer_7123287}} is receiving therapy I may leave the premises. However, I will give The George Center for Music Therapy, Inc. a working cell phone number where I can be reached during my absence. In addition, I agree that I will return 10 minutes prior to the end of the end of the session. I give consent and permission to The George Center for Music Therapy, Inc. for any additional treatment or transportation that may be needed in the event that {{answer_7123287}} is injured or needs medical attention.

Also, I understand that the ability to continue to leave the premises while {{answer_7123287}} is at therapy is at the discretion of The George Center for Music Therapy, Inc. and/or the patient's therapist.


I hereby release The George Center for Music Therapy, Inc., and any agents or assignees, from any and all claims for damages related to my leaving the premises during therapy.

*

     
 
Please list a cell number where someone can be reached in emergency: *

 
CONSENT FOR AUDIO/VISUAL RELEASE  
I, {{answer_7123287}}, or legal guardian, {{answer_7123336}},  give permission for audio or video taping to be done by the therapists at The George Center for Music Therapy, Inc. These audio or video taped sessions will be used for education and training purposes only (i.e., clinical supervision, conference presentations). At no time will the patient’s full name be spoken on the tapes and the patient’s full identity will remain confidential. These tapes may be maintained in a locked facility.

I understand and agree to the above statement. *

     
 
CONSENT FOR PHOTOGRAPH RELEASE  
I, {{answer_7123287}}, or legal guardian, {{answer_7123336}} give permission for {{answer_7123287}} to be photographed by the therapists at The George Center for Music Therapy, Inc.  These photographs will be used for education and training purposes (i.e., clinical supervision, conference presentations), and may be used by The George Center for Music Therapy, Inc. for advertisement purposes (i.e., brochures, newspapers).

I understand and agree to the above statement. *

     
 
OBSERVATION RELEASE

The George Center is a learning facility. We often have students and interns shadowing our therapists for educational purposes. 

Please indicate if a student or intern is allowed to observe your music therapy session.
*

     
 
HIPPA POLICY

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. 
*

PLEASE REVIEW IT CAREFULLY.

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. 
 

OUR LEGAL DUTY   

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect January 20, 2015, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. 

We reserve the right to makes changes in our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice Available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or additional copies of this Notice, please contact us using the information listed at the end of this notice. 

USES AND DISCLOSURES OF HEALTH INFORMATION   

We use and disclose health information about you for your treatment, payment, and health care operations. For example:

Treatment: We may use and disclose your health information to a physician or other health care provider proving treatment to you.   

Payment: We may use and disclose your health information to obtain payment services we provide to you.

Health care operations: We may use and disclose your health information in connection with our health care operations. Health care operations include quality assessment and improvement activities, reviewing the competence of qualification of health care professionals, evaluating practitioner performance, conducting training programs, accreditation, certification, licensing, and credential activities. 

Your Authorization: In addition to our use of your health information for treatment, payment or health care operations you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use of disclosures permitted by your authorization while it was in effect. Unless you give us written authorization, we cannot use or disclose your health information for any reason except those describes in this Notice. 

To your family and friends: We must disclose your health information to you as described in the Patient Rights section of this Notice. We may disclose your health information to a family, member, friend or other person to the extent necessary to help with your health care or with payment for your health care, but only if you agree that we may do so. 

Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, or your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object such uses and disclosers. In the event of your incapability or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your health care. We will also use our professional Privacy Notice Page 2 of 2 judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays or other similar forms of health information. 

Marketing Health-related Services: We will not use your health information for marketing communications without your written authorization. 

Required by Law: We may use of disclose your health information what we are required to do so by law. 

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may not disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. 

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances. 

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voice mail message messages, postcards, or letters). 

PATIENT RIGHTS 

Access: you have the right to inspect and obtain a copy of your protected health information, with limited exceptions. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing, or other cost incurred by us as a result of complying with your request. Requests for access to your protected health information must be made in writing. 

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other that treatment, payment, health care operations and certain other activities, for the last 6 years, but not before January 20, 2015. You must make your request in writing. If you request this accounting more than once in a 12 month period, we may charge you a reasonable, cost-based fee responding to these additional requests. You have the right to obtain a paper copy of this Privacy Summary Notice as well as the Full Privacy Notice. 

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). You must make your request in writing. 

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternate locations. (You must make your request in writing.) Your requests must specify the alternative means or location, and provide satisfactory explanation will be handled under the alternative means location you request. 

Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. 

Right to Express Complaints: You have the right to express complains to us and to Secretary of the Department of Health and Human Services if you believe that your privacy right have been violated. If you wish to complain to us, you must do so in writing, and direct your complaint to the Privacy Leader. 

QUESTIONS AND COMPLAINTS  

If you want more information about our privacy practices, or have questions or concerns, please contact us. 

If you are concerned that we may have violated your privacy rights, or disagree with a decision we made access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services upon request.   

We support your right to privacy of your health information. You will not be penalized in any way if you choose to file a complaint with us and/or with the U.S. Department of Health and Human Services. 

For more information about HIPAA or to file a complaint:
The U.S. Department of Health and Human Services Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
877-696-6775.
     
 
ACKNOWLEDGEMENT *

I understand and agree to the George Center for Music Therapy, Inc., Notice of Privacy Practice
     
 
Date of acknowledgment: *

 
Thank you for taking time to fill out this very important information! 

Please make sure to hit the SUBMIT button to ensure that your information is sent.

We look forward to working with you!

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