Please check areas in which your child has difficulty or needs help:

Transcription

1 Please check areas in which yur child has difficulty r needs help: Fine Mtr Skills: Management f clthing fasteners Ability t tie shes Scissrs skills Pencil grasp Clring accuracy Ability t pen snack and drink cntainers Sharpening pencil Bdy in Space Skills: Ability t stay seated in chair Sitting tlerance n flr Waiting/walking in line Navigating playgrund Space between self and thers in line Sensry Prcessing Skills: Tlerance f nise Tlerance f tactile sensatins Tlerance f mvement Engages n self-stimulatry behavir Ability t plan new mvement patterns Grss Mtr Skills: Difficulty with running, jumping, hpping Difficulty with ball skills: catching, kicking Pr sitting balance in chair, n flr Pr perfrmance in physical educatin classes On playgrund fatigues easily/becmes shrt f breath Gait/Balance: Difficulty walking: awkward gait, walks n tes Falls frequently Difficulty with stairs n bus, curbs, etc Needs assistance t walk Uses assistive devices Functinal Schl Skills: Management f clthing in bathrm Management f cat/mittens/hat Management f backpack/lunchbx Walks with tray in cafeteria Ability t handle transitins Visual Mtr/Visual Perceptual: Legibility f handwriting Fluidity f handwriting Ease f getting thughts n paper Quality f drawings Quality f pencil pressure Frequency f letter/ Number reversals Activities f Daily Living: Help with dressing She tying Hair cmbing, tth brushing Eating with/withut utensils Bathing Tileting/ptty training Equipment: Needs training in wheelchair prpulsin Needs psitining equipment fr sitting, feeding Uses walker, crutches, ft/leg, rthtics Equipment in need f repair Develpmental Milestnes: Held head up at mnths Sat at mnths Rlled ver at mnths Crawled at mnths Pulled t stand at mnths Walked at mnths Print Child s Name DOB Parent Signature Date Cleveland Rad, Suite 104, Garner, NC Phne: Fax:

2 Patient Histry Questinarre Patient Name: Sex: DOB/Age: Address: Patient Phne: Diagnsis Parent/Guardian Infrmatin: Name: Relatinship: Address: Phne: / Wrk Infrmatin: MOC Emplyer: Phne: F-OC Emplyer: Phne: Insurance Infrmatin #1 Insured Name: Insured SSN: Grup Name: Grup Number: Insured s Address, if different frm Patient: Plicy #: Relatin t Pt. Insured s Date f Birth: Insurance Infrmatin #2 Insured Name: Insured SSN: Grup Name: Grup Number: Insured s Address, if different frm Patient: Plicy #: Relatin t Pt. Insured s Date f Birth: PCP Infrmatin Name: Phne: Fax: Emergencey Cntact Name: Phne: I certify that this infrmatin is true and crrect t the best f my knwledge. I will ntify Aslan Pediatric therapy f any changes in the abve infrmatin within 30 days. I hereby authrrize Aslan Pediatric Therapy t furnish the insured s insurance cmpany all infrmatin which may be requested cncerning my child. I hereby assign Aslan Pedicatirc Therapy any mney fr which I am paid fr medical expenses related t services perfrmed at the clinic. Signature Date Cleveland Rad, Suite 104, Garner, NC Phne: Fax:

3 Release r Obtain Medical Infrmatin Page 1 f 2 I authrize the physical, ccupatinal, and speech therapists and supprt staff f Aslan Pediatric Therapy cnsent t release any r all pertinent medical infrmatin t the referring physician and any additinal physicians listed belw t maintain quality f care. Furthermre, I authrize Aslan Pediatric Therapy t release infrmatin t insurance prviders t crdinate payment f benefits. I understand that I have the right t revke this authrizatin by written request at any time, except if the prgram r persn, which is t make the disclsure, has already acted n it. I understand that authrizing the disclsure f this health infrmatin is vluntary, and I d nt need t sign this frm in rder t be eligible fr evaluatin. I understand that I have the right t cpy and inspect the infrmatin t be disclsed. Hwever, therapy treatment can nt be prvided withut disclsure. I understand that any disclsure f infrmatin carries with it the ptential fr an unauthrized re-disclsure and the infrmatin may nt be prtected by federal cnfidentiality rules. PLEASE ENTER NAME AND NUMBER OF EACH Pediatrician: Case Manager: Other agencies/therapists (OT/PT/SLP/DT): Hspitals/Clinics/Health Departments: Schl System: CDSA: Neurlgist: Develpmental Pediatrician: Opthmlgist/Optmetrist: Scial Wrker: Psychlgist: Other: Parent initials Cleveland Rad, Suite 104, Garner, NC Phne: Fax:

4 Release r Request f Medical Infrmatin Page 2 f 2 I acknwledge receipt f infrmatin and the Ntice f Privacy Practices between Aslan Pediatric Therapy and the abve named agencies/facilities and understand the cnditins under which infrmatin will be used and disclsed. I understand the types f infrmatin that may be disclsed t the abve named persns. This authrizatin will be in effect until discharge. I understand that I can add t r remve authrizatin f any persn at any time in writing t Aslan Pediatric Therapy. I understand that I have the right t revke this authrizatin by written request at any time, except if the prgram r persn, which is t make the disclsure, has already acted n it. I understand that authrizing the disclsure f this health infrmatin is vluntary, and I d nt need t sign this frm in rder t be eligible fr evaluatin/therapy. I understand that I have the right t cpy and inspect the infrmatin t be disclsed. Hwever, we will nt be able t treat withut disclsure. I understand that any disclsure f infrmatin carries with it the ptential fr an unauthrized re-disclsure and the infrmatin may nt be prtected by federal cnfidentiality rules. Patient Name: Signature (Parent/Guardian/Legal Representative) Address: Please released recrds/infrmatin shuld be sent t: Aslan Pediatric Therapy Cleveland Rad, Suite 104 Garner, NC Cleveland Rad, Suite 104, Garner, NC Phne: Fax:

5 TREATMENT CONSENT FORM Childs Name: I, (Parent r legal guardian) gives my cnsent fr Aslan Pediatric Therapy t prvide the services listed belw: Evaluatin Treatment Other (Please specify): I allw this treatment t be perfrmed at the fllwing treatment sites: Office Daycare Schl Hme Authrizatin fr Supervisin during Therapy Sessins: The fllwing peple may be present in the absence f the parent/guardian during therapy sessins: Parent Signature: Cleveland Rad, Suite 104, Garner, NC Phne: Fax:

6 PROTECTED HEALTH INFORMATION (PHI) I cnsent fr Aslan Pediatric Therapy t use the patient s Prtected Health Infrmatin (PHI) fr the purpse f prviding treatment, payment f services, and fr Aslan Pediatric Therapy general healthcare peratins purpses. PHI means fr any infrmatin, including demgraphic infrmatin, created r received by Aslan Pediatric Therapy that relates t past, present r future health cnditins: infrmatin that relates t the prvisin f health care; infrmatin that relates t past, present r future payment fr the prvisin f health care services; and infrmatin that can be used t identify the patient. I have received the ntice fr Privacy Practices and understand the cnditins under which infrmatin will be used and disclsed. Signature: I have received the Aslan Pediatric Therapy Plicy regarding my Health Infrmatin Rights under HIPAA, CFR Signature: Cleveland Rad, Suite 104, Garner, NC Phne: Fax:

7 Patient Billing Infrmatin/ Financial Plicy I hereby authrize Aslan Pediatric Therapy t charge my credit card fr my child s Occupatinal Therapy, Physical Therapy, and/r Speech Therapy services. I understand that Aslan Pediatric Therapy financial plicy states that I am required t have a credit card authrizatin n file t prcess c-pays fr services. *See financial plicy referencing c-insurance, cpays, and deductibles. Signature: Credit Card Authrizatin Patient s Name: Name as it appears n card: Credit Card Number: Verificatin Cde (last three digits n signature panel): Card Type: Visa MasterCard Discver Debit HSA Expiratin Zip Cde f billing address: Authrizatin fr Billing and Payment f Services: I authrize Aslan Pediatric Therapy t cntact Medicaid and/r private insurance cmpany t cnfirm benefits and release infrmatin necessary t prcess claims. I authrize payment directly t Aslan Pediatric Therapy fr services rendered. I understand that I am respnsible fr any c-pay/c-insurance and/r deductible amunts assciated with the patient s benefits. I understand that it is my respnsibility t knw my benefits and that verificatin f benefits by Aslan Pediatric Therapy is nt a guarantee f payment. Signature: Date Cleveland Rad, Suite 104, Garner, NC Phne: Fax:

8 *Financial Plicy and Cnsent It is required that all patients be accmpanied by a parent r legal guardian at the time f the initial visit. We require a 24-HOUR ADVANCED NOTICE FOR ALL CANCELLATIONS. Three n-shw appintments ver a three mnth perid will result in a discntinuatin f services. If yu arrive late fr yur scheduled appintment time, yu may be required t reschedule s that ther patients are nt incnvenienced. C-payments, if dictated by yur insurance plicy, are due at the time f service. Patients will be respnsible fr the remained f their bill nt paid by insurance. Payments must be made within 30 days f receipt f statement. A credit card, prvided at the time f the initial visit, will be billed fr statements mre than 45 days late, unless previus payment arrangements are made. 18% interest will be applied t all payments that are nt made within 30 days f statement. Statements nt paid within 30 days will result in an immediate discharge frm therapy. Statements nt paid within 90 days are subject t cllectins. All checks returned t us fr nn-sufficient funds will result in a $35 prcessing fee. The riginal check amunt plus the prcessing fee must be paid at yur next appintment r within 10 days. Patients Rights and Respnsibilities Be treated with respect t and have the right t privacy Receive care that is cnsiderate and respects my persnal values and belief system Persnal privacy and cnfidentiality f infrmatin Reasnable access t care, regardless f my race, religin, gender, ethnicity, age r disability Participate in an infrmed way in the decisin making prcess, regarding treatment planning and implementatin f services, frm referral t discharge Discuss with treating prfessinals apprpriate r medically necessary treatment ptins fr my child s cnditin, regardless f cst r benefit cverage Services prvided in the mst apprpriate and least restrictive manner Freedm frm unnecessary restraint r drugs Receive assessment and treatment infrmatin in an understandable manner Accept r refuse services and the right t refuse t participate in research prgrams and prjects The right t file a grievance regarding vilatins f yur human rights and receive a timely respnse The right t individualized prgramming and sensitive treatment practices Request infrmatin regarding the qualificatins f staff members wh prvide yur services Transitin services as necessary and apprpriate I understand that I am respnsible fr: Aslan Pedicatric Therapy Prviding (t the extent pssible) the treating therapist(s) with infrmatin needed in rder t receive apprpriate care Fllwing plans and instructins fr care that I have agreed upn with the treating therapist(s) Understanding my health prblems and participating, t the degree pssible, in develping, with the treating therapist(s), mutually agreed upn treatment gals Payment f the balance f treatment services nt cvered by insurance. I AGREE AND CONSENT TO PARTICIPATE IN THE THERAPY SERVICES OFFERED AND PROVIDED BY THE PEDIATRIC THERAPY CLINIC, INC. I UNDERSTAND THAT I AM CONSENTING AND AGREEING TO THOSE SERVICES. I HAVE READ AND UNDERSTAND THE FINANCIAL POLICY OF ASLAN PEDIATRIC THERAPY CLINIC. I HAVE READ AND UNDERSTAND THE PATIENT RIGHTS AND RESPONSIBILITIES. Respncible Party Signature: Print Yur Name: Childs Name: Date f Birth: Cleveland Rad, Suite 104, Garner, NC Phne: Fax:

9 ATTENDANCE/CANCELLATION POLICY Aslan Pediatric Therapy takes the care f ur patients and their families very seriusly. It is very imprtant t us that yu attend yur regularly scheduled appintments. These scheduled appintments are part f a recmmended treatment plan aimed at imprving health, functin, and the verall quality f life f ur patients. Withut regularly attending yur scheduled appintments, the benefits f therapy will be limited. In additin, several children are waiting t receive therapy services during ptimal times such as afternns fllwing schl r in the evenings when parents are hme frm wrk. Due t the high number f individuals in need f these times, Aslan Pediatric Therapy, wuld like t make every effrt t accmmdate thse in need and wh are available t make their appintment times. If yu need t cancel yur visit, please infrm yur therapist as sn as pssible, and mre than 4 hurs in advance. Hwever, we understand that ccasinally emergencies arise r children becme suddenly ill, etc. Please ntify us as sn as yu are aware that yur child will nt be attending his/her therapy sessin fr these reasns. This will allw us t plan ur schedules accrdingly. We will make every effrt t reschedule yur visit in the same week if pssible. If n prir cancellatin is made, r cancellatin ccurs with less than 24 hur ntice (with the exceptin f illness/emergencies) a $50.00 fee will be charged. Aslan Pediatric Therapy als reserves the right t discharge yur child after tw missed sessins withut prir cancellatin. If yur child is seen in the hme, an adult must be n the premises at all times while ur representative is prviding therapy. If yur child is seen in the clinic and yu wuld like t step ut t run an errand, yu may d s. Hwever, we d ask that yu arrive back in the clinic at least 10 minutes prir t the time yur child s therapy sessin ends. Child s Name (please print): Parent Signature: CHILD ILLNESS POLICY Please keep yur child hme frm therapy under the fllwing cnditins: Fever/vmiting within the past 24 hurs (this includes a lw grade temperature) Highly cntagius cnditins, including the flu, stmach virus, diarrhea, cnjunctivitis (pink eye), head lice, ring wrm, etc. Severe respiratry prblems (i.e. thick r dd-clred nasal discharge, sever cughing, etc.) Please ntify yur therapist if yur child has been expsed t/cntracted any cntagius illnesses, fr example; strep thrat, fifth s disease, chicken px, etc. Thanks fr helping us minimize the spread f illnesses t ur therapists and ther patients! Parent Signature: Cleveland Rad, Suite 104, Garner, NC Phne: Fax:

10 HIPAA PRIVACY POLICY Yur privacy matters: In 1996, Cngress passed legislatin t prvide cntinuity f cverage when individuals switch health plans and t ensure the security and privacy f prtected health infrmatin. ASLAN PEDIATRIC THERAPY has always been cmmitted t prtecting individuals' health infrmatin and will cntinue its cmmitment by ensuring cmpliance with the Health Insurance Prtability and Accuntability Act (HIPAA) privacy requirements. This rule the first federal rule t prtect the privacy f health infrmatin establishes basic natinal privacy standards fr healthcare prviders, health plans and healthcare clearinghuses t fllw, in rder t prtect patients and encurage them t seek needed care. The HIPAA Privacy Rule grants healthcare cnsumers several rights regarding their privacy and prtected health infrmatin. Aslan Pediatric Therapy has instituted dcuments, plicies and prcedures that address these rights. These include the right t: Receive Aslan Pediatric Therapy s Written Ntice f Privacy Practices, which details individual rights and prvides examples abut hw health infrmatin is used fr treatment, payment, and health care peratins. Request a restrictin n specific uses and disclsures f prtected health infrmatin. Receive cnfidential cmmunicatins f health infrmatin. Access, inspect and cpy prtected health infrmatin. Request amendment and/r crrectin f prtected health infrmatin. Receive an accunting f disclsures f prtected health infrmatin. File a cmplaint with Aslan Pediatric Therapy and with The Department f Health and Human Services (DHHS). What Aslan Pediatric Therapy is ding t prtect yur privacy: Aslan Pediatric Therapy has taken a very active rle in preparing fr this legislatin t ensure that yur right t prtected health infrmatin is recgnized. We have appinted a Privacy Officer. She is respnsible fr helping Aslan Pediatric Therapy reach its privacy gals and als t address cncerns frm patients, family and staff relating t cnfidentiality issues. We have prepared a Ntice f Privacy Practices fr yu. This dcument tells yu what we d with yur health infrmatin and what yur rights are. This dcument is available during registratin r yu may request yur wn by calling and asking fr a cpy f the Ntice f Privacy Practices. Privacy Fact Sheets available t cnsumers: The Department f Health and Human Services (DHHS) Office fr Civil Rights (OCR) privacy listserv ffers tw fact sheets available n its Web site. The first, "Privacy and Yur Health Infrmatin," prvides a general verview f the HIPAA privacy rule and individual rights assciated with the rule. The secnd, "Yur Health Infrmatin Privacy Rights," fcuses n each f the privacy rights included under the rule. Bth sheets can be btained frm the OCR Web site at I have received and read Aslan Pediatric Therapy s HIPAA Plicy. Patient Name (printed): Date f Birth: Parent/Guardian Signature: Cleveland Rad, Suite 104, Garner, NC Phne: Fax:

11 WAIVER OF H.I.P.A.A. LIABILITY Due t federal guidelines prtecting all private patient health infrmatin, Aslan Pediatric Therapy has a plicy in place that prhibits discussin f all infrmatin regarding yur child s assessment, treatment and care, in public areas such as the patient waiting rm r in the pen treatment clinic. All discussin regarding yur child/children will take place in a private rm away frm the general public. By signing this waiver f H.I.P.A.A. liability, yu as the parents r guardians, are releasing Aslan Pediatric Therapy frm any harm r fault caused by discussing the private health infrmatin in such pen access areas in ur facility such as the waiting rm r gym area with yu as the parent r a preferred guardian yu send t accmpany yur child t their therapy sessins. This waiver is t encurage nging discussin between the therapist and family. This waiver will be in place frm the date signed belw, until such a time that yu as the parents and/r guardians request in writing t Aslan Pediatric Therapy Therapy that all discussin take place in a private setting. Sincerely, Rnald S. Elmre, CEO Parent/Guardian Signature: Cleveland Rad, Suite 104, Garner, NC Phne: Fax:

12 Acknwledgement f Receipt f Privacy Ntice Purpse f this Acknwledgement This Acknwledgement, which allws the Practice t use and/r disclse persnally identifiable health infrmatin fr treatment, payment r healthcare peratins, is made pursuant t the requirements f 45 CFR (c)(2)(II), part f the federal privacy regulatins fr the Health Insurance Privacy and Accuntability Act f 1196 (the Privacy Regulatins ). Please read the fllwing infrmatin carefully: 1 I understand and acknwledge that I am cnsenting t the use and/r disclsure f persnally identifiable health infrmatin abut me by Aslan Pediatric Therapy (the Practice ) fr the purpses f treating me, btaining payment fr treatment f me, and as necessary in rder t carry ut any healthcare peratins that are permitted in the Privacy Regulatins. 2 I am aware that the Practice maintains a Privacy Ntice which sets frth the types f uses and disclsures that the Practice is permitted t make under the Privacy Regulatins and sets frth in detail the way in which the Practice will make such use r disclsure. By signing this Acknwledgement, I understand and acknwledge that I have received a cpy f the Privacy Ntice. 3 I understand and acknwledge that in its Privacy Ntice, the Practice has reserved the right t change its Privacy Ntice as it sees fit frm time t time. If I wish t btain a revised Privacy Ntice, I need t send a written request fr a revised Privacy Ntice t the ffice f the Practice at the fllwing address: 5465 Rute 8, Gibsnia, PA 15044, Attentin: Practice Cmpliance Directr 4 I understand and acknwledge that I have the right t request that the Practice restrict hw my infrmatin is used r disclsed t carry ut treatment, payment r healthcare peratins. I understand and acknwledge that the Practice is nt required t agree t restrictins requested by me, but if the Practice agrees t such a requested restrictin it will be bund by the restrictin until I ntify it therwise in writing. I request the fllwing restrictins be placed n the Practice s use and/r disclsure f my health infrmatin (leave blank if n restrictins): I understand the freging prvisins, and I wish t sign this Acknwledgement authrizing the use f my persnally identifiable health infrmatin fr the purpses f treatment, payment fr treatment and healthcare peratins. BY SIGNING THIS FORM, I ACKNOWLEDGE THAT I HAVE REVIEWED AN EXECUTED COPY OF THIS ACKNOWLEDGEMENT AND A COPY OF THE PRACTICE S POLICY NOTICE AND AGREE TO THE PRACTICE S USE AND DISCLOSURE OF MY PROTECTED HEALTH INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS. Signature f Guardian Patient s Name Date f Birth Scial Security Number Date Cleveland Rad, Suite 104, Garner, NC Phne: Fax:

13 FIRST AID PARENTAL PERMISSION FORM I give permissin fr Aslan Pediatric Therapy staff t prvide first aid as needed t my child in case f an emergency. I als give Aslan Pediatric Therapy staff permissin t seek medical assistance in case f an emergency. I will nt hld Aslan Pediatric Therapy liable fr accidents that may happen in my absence. If yu have discussed leaving the ffice while yur child is in therapy and yu have discussed this with yur therapist and they are in agreement, please prvide the fllwing infrmatin: Cell phne r emergency cntact number: Signature Cleveland Rad, Suite 104, Garner, NC Phne: Fax:

14 Aslan Pediatric Therapy Newsletter Aslan Pediatric Therapy creates and distributes a mnthly newsletter which is available t ur families, as well as medical ffices and preschls within the cmmunities we serve. This allws us t prvide in-depth infrmatin n varius tpics within ur therapists many specialties, articles regarding specific diagnses and additinal areas f interest, as well as t prvide infrmatin n cmmunity and special events in which Aslan Pediatric Therapy is invlved. We ffer the ptin fr ur families t receive ur newsletter via . If yu wuld like t be added t ur newsletter distributin list, please prvide yur child s name and yur address belw. Thanks! Patient Name: address: Cleveland Rad, Suite 104, Garner, NC Phne: Fax:

15 PHOTO/VIDEO RELEASE FORM Child s Name: I, (Parent/Guardian s name) give permissin fr Aslan Pediatric Therapy t take and display/ pictures f my child. These pictures will be used fr prmtinal and educatinal purpses nly. Yur child s name will nt be included with the pictures. Educatinal Slide shw Aslan Pediatric Therapy Website Opt OUT I, (Parent/Guardian s name) give permissin fr Aslan Pediatric Therapy t take vide ftage f my child. These vides will be used fr prmtinal and educatinal purpses nly. Yur child s name will nt be included with the vides. Educatinal Slide shw Aslan Pediatric Therapy Website Opt OUT Parent Signature: Cleveland Rad, Suite 104, Garner, NC Phne: Fax: