Registration Form Step 1 of 11 - Patient Information 0% Are you currently located in the European Union (EU)?* Yes No I have read and understood the UW's Privacy Policy with respect to EU entities* Yes Click here to view UW Privacy Policy NOTE: Our Tacoma branch is not currently offering ABA services. Patient InformationName* First Middle Last Date of Birth Month Day Year NOTE: UWAC is not accepting requests for adult (18+) diagnostic evaluations at this timeAddress* Street Address Apartment # City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Ethnicity Category Asian African American White Hispanic Native American Pacific Islander If of more than one ethnicity, please specify all.Specific Ethnicity/Race How would you like us to refer to your child's ethnicity/race (e.g. of a specific country/nation name, mixed/multi, Asian vs. Asian-American, etc.)?HiddenLast Four Digits of SSNGender* Boy/Man Girl/Woman Non-Binary Prefer Not To Say Would you like to further specify the client's pronouns, etc.? Yes No Start of Supplemental Gender SectionPreferred/True Name Legal Name Pronouns (e.g. he/him, she/her, they/them, xe/xem): Assigned pronouns: How would the client like to be referred to in clinical reports? Transgender Nonbinary How would the client like to be referred to in clinical reports? Individual Male Female Person How would the client like to be referred to in the waiting room? Preferred/True name Legal name Preferred/True pronouns Assigned pronouns How would the client like to be referred to in their clinical report? Preferred/True name Legal name Preferred/True pronouns Assigned pronouns How would the client like to be referred to when talking to their family? Preferred/True name Legal name Preferred/True pronouns Assigned pronouns How should clinicians refer to the client with other professionals (e.g. prescribers)? Preferred/True name Legal Name Preferred/True pronouns Assigned pronouns Is there anything else you would like us to know about the client's gender?End of Supplemental Gender Section Person Completing this FormName* First Last Parent/Guardian/Other* Caregiver Category Biological Parent(s) Foster Parent(s) Grandparent(s) Legal Guardian Other Relatives Other None HiddenAuthorized to consent for this individual's health care? Yes No Primary Phone Number*Who typically answers this phone?* First Last Best Time to Call* OK to leave a message at this number?* Yes No Second Phone NumberWho typically answers this phone? First Last Best Time to Call OK to leave a message at this number? Yes No Third Phone NumberWho typically answers this phone? First Last Best Time to Call OK to leave a message at this number? Yes No Is the person completing this form the one paying? Yes No Guarantor (the person paying)Guarantor Name* First Last Guarantor Relationship to Client* Guarantor Phone Number*Guarantor Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Insurance Information: Primary Insurance CoveragePrimary Insurance Company Name (We're sorry that unable to accept Amerigroup at this time, if you have other insurance, select it below to continue)*MolinaPremeraUnited Health CareRegenceBlue Cross Blue ShieldAetnaKaiser PermanenteApple HealthCommunity Health Plan of WACignaCoordinated CareProvider OneTricareFirst ChoiceOther (Please Specify)Please Specify Primary Insurance Company Name HiddenInsurance Company Name Name of Benefit Plan* Subscriber Name* First Last Subscriber Date of Birth Month Day Year HiddenSubscriber SSN Patient Relationship to Subscriber (Self/Dependent/Spouse/Other)* Subscriber ID Number* Group Number* Provider Phone Number*Insurance Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Insurance Information: Secondary Insurance CoverageDo you have a secondary insurer? Yes No Secondary Insurance Company Name (We're sorry that unable to accept Amerigroup at this time, if you have other insurance, select it below to continue)MolinaPremeraUnited Health CareRegenceBlue Cross Blue ShieldAetnaKaiser PermanenteApple HealthCommunity Health Plan of WACignaCoordinated CareProvider OneTricareFirst ChoiceOther (Please Specify)Please Specify Secondary Insurance Company Name HiddenInsurance Company Name Name of Benefit Plan Subscriber Name First Last Subscriber Date of Birth Month Day Year HiddenSubscriber SSN Patient Relationship to Subscriber (Self/Dependent/Spouse/Other) Subscriber ID Number Group Number Provider Phone NumberInsurance Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code HiddenLegal Next of KinHiddenName First Last HiddenNext of Kin Relationship to Client HiddenNext of Kin Phone Primary Healthcare ProviderPrimary Healthcare Provider Name* First Last Clinic/Hospital* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Household and Family InformationPatient relationship status (select "Single" if client is child)* Single Married Divorced Separated Other If living with parents, indicate relationship status of parents Single Married Divorced Separated Other If parents are divorced or separated, please indicate the type of custody (joint/sole) Custody Holder Name First Last Who is responsible for medical decisions regarding the client? (If client is adult, please specify any guardianship or power-of-attorney.)* Primary language spoken in home* Other languages spoken Would you like an interpreter when you talk to us? Yes No Services Being PursuedHas patient been diagnosed with Autism?* Yes No When and by whom? Please indicate which services(s) you are interested in pursuing at the UW Autism Center. (NOTE: Currently our Tacoma branch is not offering ABA services, and neither site is accepting requests for adult (18+) diagnostic evaluations at this time.)*Diagnostic EvaluationABA ServicesSpeech & LanguageSocial Skills GroupSleep ClinicPsychological TherapyFeedingOther (note in comments)Desired Site of Service* Seattle Tacoma Either Has this client been seen at UWAC before?* Yes No Approximately when was the client seen at UWAC, and for which services?*Has patient been evaluated by a 0-3 program? Yes No If so, where and approximately when?Are there speech & language concerns about the patient? Yes No Is the patient seeing an SLP? Yes No If so, what goals are they working on? Additional Questions and CommentsWho referred you for services? Referral Category Primary Care Provider Self & Family Hospital Physician Specialist Public Health Agency School Other Health Professional Other/Unknown/None What are some of your or the referral source's concerns regarding the client?*What is the client's school schedule, if any?What days/times generally work best for you?HiddenIf you have a flexible schedule and can easily come to the center at the last minute, we can put you on a list to be called in the event of a cancelation. Would you like to be put on this list? Yes No HiddenIf you have standing times and/or days of the week that you know you will NOT be able to come, please specify them here:Additional Comments (optional) Client Communication AgreementMay we contact you in the future to: Inform you of research study opportunities? Invite you to events (e.g. Open Houses, Benefit Dinners)? Send you our Newsletter? The UW Autism Center would like your permission to communicate with you regarding your services via email. Is this ok?* Yes No Email Address* If no, please indicate in the Additional Comments above how best to contact you (please note, this phone number will be filed as the best way to reach you in case of emergency).Individual Providers and clients may decide to use email to facilitate communication. Some Providers at UW Autism Center may communicate via email, but this agreement does not obligate all UW Autism Center Providers to communicate via email. Email may be one of many forms of communication with UW Autism Center. I want to use email to communicate to UW Autism Center Providers and staff about my/the client’s personal health care. I understand that UW Autism Center Providers and staff will use reasonable means to protect the security and confidentiality of email information sent and received. I understand that there are known and unknown risks that may affect the privacy of my personal health care information when using email to communicate. I acknowledge that those risks include, but are not limited, to: * Email can be forwarded, printed, and stored in numerous paper and electronic forms and be received by many intended and unintended recipients without my knowledge or agreement. * Email may be sent to the wrong address by any sender or receiver. * Email is easier to forge than handwritten or signed papers. * Copies of email may exist even after the sender or the receiver has deleted his or her copy. * Email service providers have a right to archive and inspect emails sent through their systems. * Email can be intercepted, altered, forwarded, or used without detection or authorization. * Email can spread computer viruses. * Email delivery is not guaranteed. Conditions for the use of email I agree that I must not use email for medical emergencies or to send time sensitive information to my/the client’s Providers. I understand and agree that it is my responsibility to follow up with UW Autism Center Providers or staff, if I have not received a response to my email within a reasonable time period. I agree that the content of my email messages should state my question or concern briefly and clearly and include (1) the subject of the message in the subject line, and (2) clear identification including client’s name, parent’s name, and telephone number in the body of the message. I agree it is my responsibility to inform UW Autism Center of any changes to my email address. I agree that, if I want to withdraw my consent to use email communications about my/the client’s healthcare, it is my responsibility to inform my/the client’s Providers or staff member only by email or written communication Understanding the use of email I give permission to UW Autism Center Providers and staff to send me email messages that include my/the client’s personal health care information and understand that my email messages may be included in my/the patient’s medical record. I have read and understand the risks of using email as stated above and agree that email messages may include protected health information about me/the client, whenever necessary . BY CLICKING SUBMIT YOU APPROVE HAVING THIS FILE SENT ELECTRONICALLY TO THE UW AUTISM CENTER
