2015 Annual Patient Paperwork Update for Existing Patients

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1 2015 Annual Patient Paperwork Update for Existing Patients

2 DATE: ͺͺͺͺ ŚĞĐŬ WƌĞĨĞƌƌĞĚ ůŝŷŝđ &ƚ tăljŷğ 'ƌğğŷǁžžě <ŽŬŽŵŽ DĂƌŝŽŶ Patient First Name: MI: Patient Last Name: Alias: Birth : / / Patient s SSN: - - Primary Physician (required): last Seen? Referring Physician: Patient Address: City: State: Zip: Parent/Guardian Name: Spouse: Parent/Guardian Address: City: State: Zip: Home Phone: Business: Fax: Cell Phone 1: Name: Cell Phone 2: Name: address: Name: Patient Gender: Male Female Primary Language: Insurance Information Primary Insurance Insurance Plan Name: Relationship to Insured: Insured s Name: Insured s Group #: Insurance ID #: Effective : Insured s Address: City: State: _ Zip: Insured s Social Security #: - - Insured s of Birth: / / Employer: Work Phone: Secondary Insurance Insurance Plan Name: Relationship to Insured: Insured s Name: Insured s Group #: Insurance ID #: Effective : Insured s Address: City: State: _ Zip: Insured s Social Security #: - - Insured s of Birth: / / Employer: Work Phone: 1

3 2015 Patient First Name: MI: Patient Last Name: Current Medications Medication Dosage Administration Times Used For Prescriber Prescribed Diseases or injuries child has had and list approximate age at which it occurred: Asthma Yes No If yes, age: Allergies Yes No If yes, age: Surgery Yes No If yes, age: Seizures Yes No If yes, age: Stroke Yes No If yes, age: Ear Infection Yes No If yes, age: Chicken Pox Yes No If yes, age: Scarlett Fever Yes No If yes, age: Pneumonia Yes No If yes, age: Broken Bones Yes No If yes, age: List Surgeries: List Hospitalizations: List Allergies: Reactions to allergies: 2

4 AGREEMENT OF BENEFITS, CONSENT AND RELEASE FORM (Please read entire form before signing) CONSENT TO TREAT: I request and give consent to Hopebridge Pediatric Specialists, its agents, employees, therapists and associates who may attend to my child to provide and perform such evaluations, therapeutic procedures and other services as are considered necessary or beneficial by Hopebridge Pediatric Specialists for my child s treatment. I acknowledge that no representations; warranties or guarantees as to the results have been made to me. Initial RELEASE OF MEDICAL INFORMATION: I hereby give my consent to Hopebridge Pediatric Specialists to provide and share requested information from my medical records to and from third party payers and or other health care providers deemed necessary. Initial ASSIGNMENT OF BENEFITS: I hereby authorize, request and assign payment directly to Hopebridge Pediatric Specialists, covering the period of treatment related past and future treatment, by all insurance carriers with whom I have coverage or from whom benefits are or may be payable to me. Initial CHILD PROTECTION: All employees of Hopebridge Pediatric Specialists are mandated by law to report any abuse or neglect or any suspected abuse or neglect of the child. These reports will be made to Indiana Child Protective Services and will remain confidential. Initial TRANSITION TO TREATMENT PROTOCOL: The comfort of your child is of the utmost importance during their time at Hopebridge. Typically we invite you to your child's first three treatment sessions. After three sessions, we ask that you wait for your child outside of our treatment area. This empowers your child to become an independent person and allows for treatment to be fully focused upon their growth. Treatment is a valuable, individualized tool that we use in guiding your child to achieve functional independence. Our therapists will ensure you are a part of your child's individualized treatment plan. After each session, your child's therapist will discuss treatment, along with any other questions or concerns you may have in a private consultation room. Family and caregiver support will aid in your child's developmental success. Initial _ Parent / Responsible Party / Guarantor 3

5 PHOTO RELEASE FORM Read and check your desired reply for each statement. After you have completed, please sign the bottom. I give permission for (child s name), to be photographed or filmed for publicity or promotional purposes Yes No to be give his/her full name used in connection with photographs or film Yes No _ Parent / Responsible Party / Guarantor ACKWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read if I so chose) and understand the Notice. Printed Patient Name Parent / Responsible Party / Guarantor Signature 4

6 AUTHORIZATION AND RELEASE OF HEALTH INFORMATION 1. I authorize Hopebridge Pediatric Specialists to release the protected health information (PHI) in its possession concerning: Patient Name: Social Security Number: Address: City: State: Zip: of Birth: / / Telephone #: 2. Please specify treatment dates and check the appropriate box of the type of PHI to be released. Treatment s: or: All Treatment s Permission to Release Data (Below) Evaluation Consultation Reports Progress Notes Quarterly Reports Discharge Summary Other Please Check All Therapies That Apply Physical Therapy Document Occupational Therapy Documents Speech Language Pathology Documents Applied Behavioral Analysis Documents Counseling Therapy Department Behavioral Health 3. Send or release the PHI to: Name: Telephone #: Address: City:State: Zip: 4. I am releasing the PHI for: Treatment Disability School Collaboration Other Litigation 5. I give permission to leave a voice message applicable to the phone numbers provided: Insurance 6. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the Clinical Director and/or Administrator. I understand that the revocation will not apply to information that has already been released in response to this authorization or to the extent that someone has already acted in reliance on this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire sixty (60) days from the date this authorization is signed. 7. I understand that there is a fee for copies of the medical records and prepayment may be required. The fees are $20.00 for the first 1-10 pages, $0.50 per page for pages and $0.25 per page for pages 51 and higher. I also understand that an additional fee, as allowed under Indiana law, will be charged for all expedited requests. 8. I understand that authorizing the obtaining/disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not to sign this form in order to assure treatment, payment for treatment, or eligibility or enrollment in health benefits. I understand that I may inspect or copy the information to be used or disclosed, as provided in 45 CFR I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules after it is released. If I have questions about obtaining/disclosure of my health information, I can contact Hopebridge Pediatric Specialists at Signature of Patient or Legal Representative Witness Verifying Signature If Legal Representative signs, state relationship to Patient 5

7 ATTENDANCE POLICY Effective: August 1, 2011 Consistent attendance is critical for the success of your child s therapy. Insurance companies require progress reports as well as information regarding attendance to determine coverage of services. Additionally, missed appointments deny another child the availability to be scheduled in that appointment time. The therapists are committed to the progression of your child s therapy and require regular attendance as outlined in the plan of care that your physician has authorized as medically necessary. 1. -CALL/-SHOW POLICY: It shall be the policy of Hopebridge Pediatric Specialists that no more than 3 nocall/no-show appointments in a 365-day calendar year shall be permitted. A reminder letter will be sent to the family for the first missed appointment, a warning letter on the second missed appointment, and a final discharge letter on the third missed appointment. A discharge summary will be sent to the referring physician % SHOW-UP POLICY: It shall be the policy of Hopebridge Pediatric Specialists that for continuity of care, regular attendance is expected. The expected attendance shall be 75% of the plan-of-care visits as outlined and deemed medically necessary by your physician and/or therapists in a 30-day period, i.e., should you be scheduled for twice a week for 4 weeks, the expectation will be that your child will attend therapy a minimum of 6 visits. In addition, it is expected that your child be on time for his/her scheduled appointment. Late arrivals and tardiness in picking up your child affect the quality of care that we can give to your child as well as others. If you are consistently more than 5 minutes late to an appointment or late to pick up your child, you may be at risk of losing your scheduled appointment time. 3. INSURANCE AND INSURANCE AUTHORIZATION HOLDS: If for any reason your insurance deems a break in service, Hopebridge Pediatric Specialists will hold your child s appointment up to and through the following week upon notice. After that last week, your child will no longer be able to hold that appointment time. Should your insurance resume, Hopebridge Pediatric Specialists will make every reasonable attempt to schedule your child at a time that is convenient to you. Print Name: Parent / Guardian / Financial Guarantor Parent / Guardian / Financial Guarantor Signature Phone Number: Permission to Leave Message: Yes No Hopebridge Witness Signature 6

8 FINANCIAL POLICY AND AGREEMENT Please read the following information carefully before signing, as there have been changes and updated information added to Hopebridge Pediatric Specialist s Financial Policy. If you have any questions, please ask a staff member to assist you. Once signed, you will receive a copy of the financial agreement for your records. In consideration of the services and treatment delivered by Hopebridge Pediatric Specialists therapists and/or other Hopebridge Pediatric Specialists personnel, the undersigned guarantees payment of the account for any non-covered services, deductible amounts, coinsurance, and co-payments due for services received at the time of service. Your insurance company (if applicable) will send you an explanation of benefits, so you will know when your deductible has been met and/or the amount of out of pocket co-pay/coinsurance has been changed. Payment is due at the time of service. Hopebridge Pediatric Specialists Insurance and Billing Staff will file your insurance claims for you as a courtesy, even if you have primary and secondary coverage. You will receive a monthly statement after we receive an explanation of benefits from your insurance carrier(s) that outlines the amounts due by the patient and/or responsible party. We do not charge interest; however if you skip a payment, a $20.00 service charge/late fee will be added to the balance due each month a payment is missed. Please call or meet with the Administrative Manager of Patient Accounts, if you need to make payment arrangements. We accept cash, checks, Master Card, and Visa. For your convenience, you may call in a Master Card or Visa payment over the phone. We can assist you in applying for a Care Credit Card account, as well. It is your responsibility to notify Hopebridge Pediatric Specialists if your insurance carrier changes, your benefits max out, or are capped for the year/lifetime, and as soon as you have a change of address, so that we can bill correctly and in a timely manner. Noncompliance may result in suspension of services for your child. By signing below, I acknowledge that I have read and understand the Financial Policy and agree to comply with the terms outlined by Hopebridge Pediatric Specialists. I also acknowledge that I may be contacted at the phone number and/or provided below. Print Name of Responsible Party / Guarantor Signature of Responsible Party / Guarantor - - Social Security Number for Responsible Party/Guarantor Mailing address of Responsible Party/Guarantor Phone number of Responsible Party/Guarantor of Responsible Party/Guarantor Witness (Hopebridge Pediatric Specialists Staff) 7

9 EMERGENCY CONTACT/PICK UP FORM Patient Name: of Birth: *Hopebridge will need to have a copy of a driver s license or photo ID on file for any person authorized to pick up. *Individuals authorized to pick up must be at least 18 years of age. Emergency Contact #1: (Primary Caregiver) Contact s Name: Relationship to Patient: Home Phone Number:_ Cell Phone Number: Permission to Leave Message: Authorized to pick up: Emergency Contact #2: Contact s Name: Relationship to Patient: Home Phone Number:_ Cell Phone Number: Permission to Leave Message: Authorized to pick: Emergency Contact #3: Contact s Name: Relationship to Patient: Home Phone Number:_ Cell Phone Number: Permission to Leave Message: Authorized to pick up: Additional people authorized to pick up patient from therapy, not listed above: 8

10 Therapeutic Options provides human service, healthcare, and educational organizations the tools to keep people safe while maintaining their commitment to positive approaches in serving individuals whose behavior sometimes poses danger to themselves or others. Our staff have received intensive training in de-escalating techniques to help support the child during crisis or emergency situations. Our focus is on primary preventions in order to meet the needs of the children we serve. However, we do recognize that there could be times in which physical personal protection and aggression management techniques may be required in order to protect the child or others. All Hopebridge therapists have completed Therapeutic Options training with a Therapeutic Options Instructor and have passed all qualifications in becoming certified individually. In the event that physical management techniques must be utilized, a thorough report will be completed by the therapist and submitted for review. They will debrief with a behavior consultant in attempt to identify the function of the behavior and replacement behaviors which can be taught to prevent the behavior from reoccurring. The child s treating therapist will discuss this incidence with you at the time of pick-up. By signing below you acknowledge that Hopebridge employees may use physical personal protection and aggression management techniques during situations in which the child is endanger to themselves or others despite a therapist s best efforts at prevention. I give permission for Hopebridge therapists to use Therapeutic Options if necessary: Signature 9

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