Patient Information Form – Pediatric Therapy Services

HIPAA- Patient Information

Step 1 of 7

Office Location*
Please select your correct location.
Child's First Name*
Child's Last Name*
Sex*
- Male
- Female
Age*
Date of Birth*
MM
DD
YYYY
Address*
City*
Zip*
Home Phone Number*
Email*
Mother's Information
First and Last Name
Cell Phone Number
Date of Birth
MM
DD
YYYY
Employer - Company Name
Work Phone Number
Father's Information
First and Last Name
Cell Phone Number
Date of Birth
MM
DD
YYYY
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

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*
MM
DD
YYYY
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*
MM
DD
YYYY
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*
MM
DD
YYYY
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*
MM
DD
YYYY
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
MM
DD
YYYY

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
MM
DD
YYYY

HIPAA- Patient Information

Step 1 of 7

Mother's Information

Father's Information

Guardian's Information

Primary Care Pediatrician

Insurance Information

General Information

Medical History

Developmental History

Speech-Language Development (check all that apply):

Gross Motor Development (check all that apply):

Fine Motor Development (check all that apply):

Family Information

Medical History

Insurance Authorization and Assignment of Benefits

Consent and Attendance

Vaccination Policy

Privacy Statement

About PTS

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