Medicaid Statement

Please note that we are NOT a Medicaid provider.  By clicking the box below you are acknowledging that you DO NOT have Medicaid.  If during the billing process it is determined you do have Medicaid, the Responsible Party will be billed for services provided and all future appointments will be canceled.
Do you have Medicaid? *

Other Health Insurance

Do you have TRICARE? *
Do you have other health insurance (OHI)? *

TRICARE is secondary to all other insurances and will not pay if we are not in network with your OHI provider.  This will result in the Responsible Party receiving a bill for services regardless if you have TRICARE or not.  Please confirm you do not have OHI.
I do not have OHI. *

Child / Adolescent Intake Form

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Gender *
Parent / Guardian's marital status: *
Married to child's bio mom / dad *
Are you the custodial / decision making parent meaning you have legal documentation stating the other parent does not have this right. OR do you have joint custodial rights and / or decision making authority?
In cases of divorce, separation, or when legal custody is not previously established above, we are required to let both custodial parents / guardians know that the child is in treatment. By selecting this box you are affirming that you are not aware of the whereabouts of the your child's other parent and you've exhausted all attempts to let them know their child is in treatment.
Please attach supporting documentation.  This could include court documents, divorce decree, adoption papers, birth certificate, etc.  If you have any questions, please contact our office at 719-540-2146 before continuing. 

Would you like to add another contact number? *
Best time to call *
Emergency contact information
 NamePhone numberRelationship
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Responsible Financial Party

We require a credit card to be placed on file.  Cards are securely filed and will be used only for payment of co-pays, co-insurance, payments for service and no-show fees.  Credit card information must be entered even if you are not the responsible party.
 
TRICARE Prime and Active Duty Service Member will not be charged a co-pay but must still put card information for any no-show fees. 
In order for us to verify the credit card information, we will run a $1 transaction and then immediately void this transaction. By checking the box below, you agree that we may charge the card for this transaction. *
Is financial responsibility someone other than the patient? *
Visa
By checking the box below, you agree that we may charge the card provided for the amount owed the day after it is reflected on the account. *

Referral Information

Presenting Problem

Notices

By checking this box, you acknowledge that you have read the notices above. *

Acknowledgement and Signature

By signing this form, you agree that you are willing to be seen by a provider at the Family Care Center and will become a client of this clinic upon submission of this form. Clients are responsible for all payments at time of service. Clients who do not show up for their initial medication appointment are subject to a $100 no-show fee. Furthermore, clients who miss a follow-up appointment for medications are subject to a $100 no-show fee.  Clients are also charged a $50 no-show fee for missed therapy appointments.  These fees must be paid prior to any further appointments being made. Two or more no-shows for an initial appointment can result in you not being accepted as a client. *
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