Hello, and welcome to The Therapy Center!
Included here are the New Patient Forms we will need filled out for your first appointment.
Please be sure to upload a photo of your ID, as well as the front AND BACK of your insurance card!
**As we have two locations, on the East Side and West Side, please verify the location and address of your clinician before your first appointment to avoid rescheduling.**
If you have any questions, feel free to contact us either via email (kathleen@therapycenterwichita.com) or by phone at (316) 636-1188.

WEST SIDE CLINICIANS:
6606 W Central Ave
Wichita, KS 67212

Date:

Full Name:

DOB:

SSN:

Address:

City/State:

Zip:

Home Phone w/area code:

Cell Phone w/area code:

Alt. Phone w/area code:

Email Address:

Primary Care Physician:

Race:

Ethnicity:

Preferred Pronouns:

Decline to specify:

IF PATIENT IS A MINOR:

Mother/Father/Legal Guardian Name(s):

Full Name:

DOB:

SSN:

Address:

City/State:

Zip:

Home Phone w/area code:

Cell Phone w/area code:

Alt. Phone w/area code:

Relationship to Patient:

Employer:

Insurance Company:

Grp#:

Member ID#/Policy ID#:

Please upload your ID Front and back

Full Name of Policy Holder:

DOB:

SSN of Insured:

Home Phone w/area code:

Cell Phone w/area code:

Alt. Phone w/area code:

Address:

City/State:

Zip:

Relationship to Patient:

Driver's License # of Policy Holder:

Full Name of Insured:

DOB:

SSN of Insured:

Home Phone:

Cell Phone:

Alt. Phone:

Relationship to Patient:

Driver's License # of Policy Holder:

Insurance Company:

Grp #

ID #

Please upload your ID Front and back

Financial Policy
PLEASE READ BEFORE SIGNING
Effective 1/1/2014

The patient/guarantor is responsible for providing The Therapy Center with current, active insurance information. A copy of the insurance card will be scanned into your chart. If your insurance changes, please notify our office immediately.

Your insurance coverage is a contract between you and your insurance carrier. You remain responsible for any portion of your bill that is not paid by your insurance carrier regardless of the reason for the carrier’s non-payment. If you do not have a secondary insurance carrier to cover any co-payments or deductibles, you are responsible for payment of such amounts. All insurance companies require co-payments be made at the time of service.

Insurance co-payments are due at time of service, prior to seeing the provider. The Therapy Center will submit claims to your primary and secondary insurance as indicated. Once the insurance has processed, an account statement will be mailed to the guarantor of the account for any non-covered services, deductibles, or co-insurance. The responsible party, named below and/or the patient agrees to pay our costs for collection amount owing, including court cost, attorneys’ fees, and collection cost. The cost of collection will not include costs that were incurred by a salaried employee of ours, will not include recovery of both attorneys’ fee and collection agency fees, and will not be in excess of fifteen percent (15%) of the unpaid debt after default.

In certain circumstances, The Therapy Center may contact your insurance in advance to inquire about coverage for special procedures or tests. If it is determined that the service is not covered or will be applied to your deductible, we may require payment in advance. The Therapy Center accepts personal checks, Visa, MasterCard, American Express, and Discover credit cards.

Please make personal checks out to your individual provider, not to The Therapy Center.

I have read and understand the Financial Policy of The Therapy Center.

Patient Missed Appointment Policy

Staff and clinicians work hard to provide you, our patients, with excellence of service with the utmost professionalism. Our commitment to your well-being is taken seriously by everyone here at The Therapy Center. Our time is as important to us as your time is to you. Missed appointments are missed opportunities for both the patient and the therapist.

With the exception of a serious emergency, it is expected that you keep all of your appointments. If you need to re-schedule an appointment, we require a 24-hour notice. In such a case, please call our office and arrange to reschedule that appointment with our Front Desk Receptionist.

In an instance of a cancellation without a 24-hour notice or no-show to a scheduled appointment, we reserve the right to charge you a cancellation fee. If you are consistently missing your scheduled visits, we also reserve the right to discontinue care.

We appreciate you greatly as our patient and strive to accomplish positive results and success for you.

I have read and understand the Patient Missed Appointment Policy of The Therapy Center.

Acknowledgement of Receipt of Notice of Privacy Practices

The Therapy Center is required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and disclose your health information. Please sign this form to acknowledge receipt of the notice. You may refuse to sign this acknowledgement, if you wish. I have reviewed the privacy practices located under patient forms on The Therapy Center website and understand a hard copy is available upon request.

I have reviewed the privacy practices located under patient forms on The Therapy Center website and understand a hard copy is available upon request.

Appointment Reminder Texts

The Therapy Center is able to send appointment reminders via text to your preferred phone number for your upcoming appointments. The appointment reminders will be from The Therapy Center, and will include the date and time of your appointment. These text messages will not be encrypted.

Healthcare information sent by text unfortunately involves certain unavoidable and uncontrollable risks: texts can be lost, delayed, intercepted, delivered to the wrong number, read by unintended recipients or arrive incomplete or corrupted. Acknowledging and understanding these risks with text messages, if you would like to receive appointment reminders by text, please sign below to confirm your acceptance of these risks and that you agree not to hold The Therapy Center and/or staff responsible for any event or consequence that might transpire after the text message has been sent. This consent can be rescinded at any time by giving written communication of your preference to your clinician.

I have read and understand the Appointment Reminder Texts Policy of The Therapy Center.

I wish to receive text reminders on my Cell Phone:

I do not wish to receive text reminders regarding my upcoming appointments.

E-Signature

Please sign electronically below.

Clear Signature

Patient Information

RESPONSIBLE PARTY/PERSON SIGNING PAPERWORK

PRIMARY INSURANCE INFORMATION

Please upload your ID Front and back

SECONDARY INSURANCE INFORMATION

Please upload your ID Front and back

Financial Policy
PLEASE READ BEFORE SIGNING
Effective 1/1/2014

Patient Missed Appointment Policy

Acknowledgement of Receipt of Notice of Privacy Practices

Appointment Reminder Texts

E-Signature

Patient Information

RESPONSIBLE PARTY/PERSON SIGNING PAPERWORK

PRIMARY INSURANCE INFORMATION

Please upload your ID Front and back

SECONDARY INSURANCE INFORMATION

Please upload your ID Front and back

Financial Policy PLEASE READ BEFORE SIGNING Effective 1/1/2014

Patient Missed Appointment Policy

Acknowledgement of Receipt of Notice of Privacy Practices

Appointment Reminder Texts

E-Signature

Financial Policy
PLEASE READ BEFORE SIGNING
Effective 1/1/2014