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HIPAA- Patient Information
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Office Location
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Please select your correct location.
Lakeland
Brandon
Child's First Name
*
Child's Last Name
*
Sex
*
Male
Female
Age
*
Date of Birth
*
Month
Day
Year
Address
*
City
*
Zip
*
Home Phone Number
*
Email
*
Mother's Information
First and Last Name
Cell Phone Number
Date of Birth
Month
Day
Year
Employer - Company Name
Work Phone Number
Father's Information
First and Last Name
Cell Phone Number
Date of Birth
Month
Day
Year
Employer - Company Name
Work Phone Number
Guardian's Information
First and Last Name
Phone Number
Address
City
Zip
Permission to leave message on answering machine/phone:
*
Yes
No
Referring Physician
Address
City
Zip
Primary Care Pediatrician
Name
Address
City
Zip
Diagnosis: Primary
Secondary
Phone
Insurance Information
Primary Insured:
Insurance Company
ID #
Group #
Phone
Secondary Insured:
Insurance Company
ID #
Group #
Phone
General Information
What is it about your child's development or medical condition that concerns you?
When was it first noticed?
Does your child become impatient or frustrated?
Describe any changes in your child's development within the past three months:
Describe your child's strengths:
Describe your child's weaknesses:
What are your goals for your child?
Medical History
History of Pregnancy
Were there any problems with the pregnancy with this child (RH incompatibility, toxemia, drug/alcohol abuse, exposure to infections/illness, unusual stress, etc.)?
Mother's Age at Delivery:
Number of Previous Miscarriages:
Labor and Delivery
Full Term?
Yes
No
If no, how early?
How late?
Birth weight:
Weight at discharge:
Apgar Scores:
Were there complications during delivery/labor? Please describe:
Check all that apply:
Cesarean Section
Transverse (sideways)
Required a birth monitor
Respirator
Jaundiced
Require exchange transfusion
Breech
Transfusion
Seizures
Birth Injuries
Cried right away
Face presentation
Cord around neck
Required forceps
Feeding difficulties
Infections
Heart defect
Was your child in a regular or special care nursery?
How long?
Age at discharge?
How was your child fed during hospitalization?
How is your child fed now?
List any congenital abnormalities:
Describe disposition/temperament (colic, sleep patterns, acceptance of being held):
Medical History of Child
Childhood Diseases (check all that apply):
Chicken Pox
Roseola
Measles
Scarlet Fever
Mumps
Whooping Cough
Any unusual problems:
Other Childhood Problems (check all that apply):
Allergies
Growth/weight problems
Meningitis/encephalitis
Recurrent ear infection/tubes
Urine/bowel problems
Vision problems
Asthma
Headaches/dizziness
Persistent drooling
Recurrent colds
Seizures
Hearing problems
Feeding problems
High fevers
Persistent vomiting
Pneumonia
Sinusitis
Clumsiness
Other:
Developmental History
The approximate age your child achieved the following developmental milestones:
Sat alone:
Crawled:
Hand preference:
Walked:
Toilet trained:
Speech-Language Development (check all that apply):
Did/does your child:
Coo, babble, vocal play
Imitate sounds, words or phrases
Play peek-a-boo, pat-a-cake
Imitate gestures (wave bye-bye, "so big")
Use single words by 12-18 months
Understand what you are saying
Retrieve/point to common objects upon request
Follow simple directions (shut the door)
Respond appropriately to yes/no questions
Gross Motor Development (check all that apply):
Did/does your child:
Lift head while on stomach
Roll over
Sit alone
Creep on hands and knees
Throw ball overhand
Balance on each foot
Bear weight on legs
Pull self on tummy
Standing holding on
Stand alone
Run
Jump
Bear weight on arms
Pull to sit
Pull to stand
Walk
Walk up steps
Walk backward
Fine Motor Development (check all that apply):
Did/does your child:
Follow with eyes to center
Hold rattle
Reach for objects
Hold object with thumb & finger
Build tower with blocks
Cut on a line/around a shape
Tie shoes
Follow with eyes past center
Bring hands together
Transfer objects from hand to hand
Scribble
Copy shapes
Open/close buttons
Open/close zippers
Sensory- Did/does your child:
Have trouble falling asleep
Engage in self-stimulatory behaviors
React negatively to "normal" noises
Fear of climbing
Fall frequently
Dislike certain temperatures
Avoid being touched
Hear things most people tune out
Refuse to wear certain clothing pieces/textures
Is always in motion
Dislike certain tastes
Dislike certain textures
Family Information
Does your child interact with other children on a regular basis? (siblings, daycare, school, babysitter, play group)
Behavior patterns (check all that apply):
Interacts well with children/adults
Cooperative
Imitates actions/gestures/speech
Easily distracted/short attentiont
Withdrawn
Dislike certain temperatures
Destructive
Can play alone for reasonable length of time
Attentive
Tries new activities
Separation difficulties
Easily frustrated/agitated
Poor eye contact
Aggressive
Withdrawn
Inappropriate behaviors
If yes to inappropriate behaviors, please list:
Medical History
Patient's Specialists (list all):
Are there any changes in your doctors?
*
Yes
No
If yes, please list:
Any changes or additions to diagnosis?
Yes
No
If yes, please list:
Please list your current medication(s) using the following format: Name/ Dose/ Frequency/ Purpose/ Method
Method choices might include: PO, IV, NG, Nebulizer, Aerosol.
List child's equipment:
School, Daycare or Preschool child attends:
Grade:
Other outside therapy?
PT
OT
ST
If yes, name of provider:
Frequency of each:
In school setting?
PT
OT
ST
Frequency:
PROVIDE MOST CURRENT EVALUATIONS FROM PROVIDER.
Does child require special diet/restrictions?
Yes
No
If yes, please list:
Areas of concern:
Safety issues:
Therapy goals?
The information above has been completed to the best of my knowledge and ability.
Full Name
*
Relationship to Patient
*
Insurance Authorization and Assignment of Benefits
I hereby authorize Pediatric Therapy Services, Inc. to furnish all information to insurance carriers and/or Medicaid concerning the patient's diagnosis and or treatments. I hereby assign to PTS, Inc. (providers) all payments for therapy and related services rendered to my dependents.
Patient's First Name
*
Patient's Last Name
*
Should the insurance company send payment directly to me, I will endorse said check over to Pediatric Therapy Services, Inc.
Initial
*
I understand that I am responsible for any amount not covered by insurance: this includes any course of treatment that is not a covered benefit, including DME products.
Initial
*
I understand that I am responsible for notifying Pediatric Therapy Services, Inc. of any changes in my insurance coverage.
Initial
*
If I am delinquent in updating this information and charges are denied, I understand that I am responsible for these charges.
Initial
*
I understand that I may be charged 1.5% interest rate per month on any unpaid balance and that I am responsible for any costs incurred in collection of said balance should that become necessary.
Initial
*
I understand that I will be charged a $25 fee for “No Show” appointments.
Initial
*
I authorize Pediatric Therapy Services, Inc. to initiate a complaint to the Insurance Commissioner for any reason on my behalf.
Initial
*
I give my consent for Pediatric Therapy Services, Inc. to appeal claims to my insurance company on my behalf.
Initial
*
I give my consent for Pediatric Therapy Services, Inc. to appeal authorizations to my insurance company on my behalf.
Initial
*
I give my consent for Pediatric Therapy Services, Inc. to appeal authorizations to my insurance company on my behalf.
Initial
*
My signature below indicates that I am the legal guardian of this patient and that I understand and accept this policy.
Initial
*
First Name
*
Last Name
*
Signature
*
Relationship to Patient
*
Consent and Attendance
Patient First Name
*
Patient Last Name
*
Attendance Policy
Welcome to Pediatric Therapy Services, Inc. (PTS) Beginning in a therapy program is a big step and a real commitment. Our entire staff is committed to providing you and your family with the professional services and timely information that you will need in order to progress in your therapy goals. We also need your commitment of consistent attendance and diligent effort to make our partnership a success. If you must cancel a therapy session, we ask that you call us as far in advance as possible. We feel strongly that consistent attendance is important to the success of your therapy program. We have developed specific procedures to clarify our expectation of your attendance. We ask you to follow the procedures listed below. I understand and agree to the following related to attendance of my therapy sessions
I understand that consistent attendance of scheduled therapy sessions is critical to improvement and progress.
I believe that attending therapy sessions is a commitment I am ready to make.
I understand that if the commitment becomes difficult for me to meet I will discuss it with the front office and we can work toward a solution
I will notify PTS of planned absences or vacations in advance.
I will phone PTS before my appointment time if I am unable to attend my therapy session. If I do not call, my absence will be considered a “no show.”
If I “no show” for a scheduled appointment, I will not be placed on the schedule again until PTS receives a phone call requesting an appointment.
First and Last Name
*
Relationship to Patient
*
Signature
*
Date
*
Month
Day
Year
OBSERVATION/ASSISTING PERMISSION
PTS participates with local colleges, universities and interested volunteers in allowing observation and assisting experiences within therapy sessions. This community service allows interested persons to gain information about the various disciplines and professional roles and responsibilities. These individuals are counseled prior to their observation and/or therapy assisting activities regarding confidentiality of patient information, and agree to abide by PTS policies on confidentiality as part of their observation and assisting experience.
(I do/do not) give permission for observations and/or assisting of supervised therapy sessions.
*
I do
I do not
First and Last Name
*
Relationship to Patient
*
Signature
*
Date
*
Month
Day
Year
PHOTO/MARKETING RELEASE
(I do/do not) give my permission to PTS to take picture(s) and/or video of my child.
*
I do
I do not
Picture/videos may be used for HEP, display, education, website and/or marketing.
First and Last Name
*
Relationship to Patient
*
Signature
*
Date
*
Month
Day
Year
CONSENT FOR MEDICAL TREATMENT/THERAPY TREATMENT
I give permission to PTS staff to: provide therapy services and or administer medical aid or to seek and have aid provided from a qualified medical professional if the situation requires same.
First and Last Name
*
Relationship to Patient
*
Signature
*
Date
*
Month
Day
Year
This entire consent is valid from the date of my signature until closure of patient file or until I revoke it in writing.
Vaccination Policy
Statement of Intent: Pediatric Therapy Services, Inc. expects all patients to be vaccinated.
Immunizing patients against preventable diseases is a critical component of high quality medical care. In order to provide excellent care and a safe medical home for all patients, Pediatric Therapy Services is establishing a vaccination minimum standard.
Policy:
All Pediatric Therapy Services patients should be vaccinated according to the American Academy of Pediatrics endorsed vaccine schedule.
Existing patients who are not currently being vaccinated according to the AAP schedule will be dismissed from our practice.
New patients who are not adhering to the minimum vaccine schedule according to the AAP will not be permitted to begin treatment at PTS.
If patients cannot commit to this minimum vaccination standard, then Pediatric Therapy Services, Inc. will no longer be able to commit to being their pediatric therapy provider.
Once a patient notifies PTS of their decision to refuse vaccination according to the minimum standard, PTS will initiate the process necessary to smoothly transition the patient to another practice.
I understand that I am responsible for notifying Pediatric Therapy Services, Inc. of any changes in my vaccination schedule.
Initial
*
My signature below indicates that I am the legal guardian of this patient and that I understand and accept this policy.
First and Last Name
*
Relationship to Patient
*
Signature
*
Date
Month
Day
Year
Privacy Statement
I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information (PHI). I understand that this information can and will be used to:
Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly.
Obtain payment from third-party payers
Conduct normal healthcare operations such as quality assessments and physician certifications
I received, read, and understand your
Notice of Privacy Practices
containing a more complete description of the uses and disclosures of my PHI. I understand that this organization has the right to change its
Notice of Practices
from time to time and that I may contact this organization at any time to obtain a current copy of
Notice of Privacy Practices
.
Patient First Name
*
Patient Last Name
*
Email
*
Signature
*
Date
Month
Day
Year
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