Test Form Page – Pediatric Therapy Services

HIPAA3 Patient Information

"*" indicates required fields

Step 1 of 10

Office Location*

Please select your correct location.

Child's First Name*

Child's Last Name*

Name They Prefer

Child's Date of Birth*

Sex*

Male

Female

Guardian Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone Number*

Insurance Company*

Insurance ID Number*

Insurance Holder's Name*

Insurance Holder’s DOB*

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.

Name

First Last

Signature (Please type your full name here)

Relationship to Patient

Date

Insurance Authorization & 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 Name

First Last

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 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*

My signature below indicates that I am the legal guardian of this patient and that I understand and accept this policy.

Name*

First Last

Signature (Please type your full name here)

Relationship to Patient*

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 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.

Name

First Last

Signature (Please type your full name here)

Relationship to Patient

Date