UNLV ACKERMAN CENTER FOR AUTISM AND NEURODEVELOPMENT SOLUTIONS
PATIENT LAST NAME_____________________________________FIRST NAME____________________MIDDLE________
DATE OF BIRTH__________________________________SS#____________________________________ M OR F (CIRCLE)
ADDRESS______________________________________________________________________APT #______________________
CITY_______________________________________STATE_____________________________ZIP CODE__________________
HOME PHONE #____________________________WORK #____________________________CELL #_____________________
PATIENT EMPLOYER__________________________________________ PHONE #___________________________________
PATIENT EMPLOYER ADDRESS____________________________________________________________________________
CITY_______________________________________STATE___________________________ZIP CODE____________________
SPOUSES NAME______________________________________________________________PHONE #_____________________
EMERGENCY CONTACT (other than spouse) ________________________________PHONE #__________________________
REFFERED BY_____________________________________________________________________________________________
PRIMARY INSURED INFORMATION
PRIMARY GUARANTOR-INSURED NAME_______________________________________RELATIONSHIP______________
DATE OF BIRTH___________________________________SS # ___________________________________M OR F (CIRCLE)
ADDRESS________________________________________________________________________________APT #____________
CITY_______________________________________STATE___________________________ ZIP CODE___________________
HOME PHONE #_____________________________WORK #_________________________CELL #_______________________
GUARANTOR EMPLOYER____________________________________________________ PHONE #_____________________
EMPLOYER ADDRESS_____________________________________________________________________________________
CITY______________________________________STATE____________________________ZIP___________________________
INSURANCE COMPANY NAME _____________________________________EFFECTIVE DATE_______________________
POLICY ID #_________________________________________________________GROUP #______________________________
(Over Please)
SECONDARY INSURED INFORMATION
SECONDARY GUARANTOR-INSURED NAME____________________________________RELATIONSHIP______________
DATE OF BIRTH________________________________SS # ______________________________________ M OR F (CIRCLE)
ADDRESS_____________________________________________________________________APT #________________________
CITY_______________________________________STATE___________________________ZIP___________________________
HOME PHONE #_____________________________WORK #_________________________CELL #_______________________
GUARANTOR EMPLOYER_______________________________PHONE #__________________________________________
EMPLOYER ADDRESS_____________________________________________________________________________________
CITY______________________________________STATE____________________________ZIP___________________________
INSURANCE COMPANY NAME_________________________________________EFFECTIVE DATE____________________
POLICY ID #___________________________________________________GROUP #____________________________________
IF PATIENT IS A CHILD, PLEASE COMPLETE THE FOLLOWING SECTION
MOTHER’S NAME__________________________ MOTHER’S DATE OF BIRTH_______________SS#__________________
ADDRESS__________________________________________________________________APT #___________________________
CITY__________________________STATE________________ZIP CODE_________HOME PHONE #____________________
WORK #___________________MOTHER’S EMPLOYER_________________________________________________________
CHILD’S BIRTHPLACE (HOSPITAL NAME) __________________________________________________________________
FATHER’S NAME___________________________ FATHER’S DATE OF BIRTH________________SS#__________________
ADDRESS__________________________________________________________________APT #___________________________
CITY__________________________STATE________________ ZIP CODE_________HOME PHONE#____________________
WORK#_______________________________FATHER’S EMPLOYER_______________________________________________
ASSIGNMENT OF BENEFITS:
I hereby authorize the release of information necessary to file a claim with my insurance company. I assign benefits to be paid to Grant A
Gift Autism Foundation/UNLV Ackerman Autism Center and I understand that I am financially responsible for charges for medical services
rendered to the above named patient regardless of insurance coverage, including any amount related to immunizations. In the event of
collection proceedings due to lack of payment on my part, I agree to pay any and all collection fees that may be added to my account in
order to recover monies due.
Patient or Guarantor Signature__________________________________________ Date_____________________________
FOR RELEASE OF INFORMATION:
Federal law requires that we seek your acknowledgement of receipt of the Notice of Privacy Practices. Please sign below.
I acknowledge that I have received the notices: HIPAA Notices Of Privacy Practices with an effective date of April 14, 2003, and, I
understand that if I have any questions regarding this notice, I may contact the Privacy Officer.
Signature of Patient/Legal Guardian: _____________________________________Date:____________________________
Patient Refused or Failed to acknowledge receipt on _________________________ Initials _________________________