Insurance and Emergency Care Information
I hereby authorize the Pediatric Therapy Clinic, Inc. to furnish the insured’s insurance company all information which may be requested concerning my child.
I hereby assign to the Pediatric Therapy Clinic, Inc. any money for which I am paid for medical expenses related to the services performed at the clinic. I also agree to above emergency information and care plan.
Medical History
List below all illnesses, accidents, and operations which the child has had.
Please check yes or no. If yes, please describe
Please check areas in which your child has difficulty or needs help. Some areas may not be age-appropriate for your child; you can leave these boxes unchecked:
Mental health questionnaire
To better understand your child’s background and previous experiences, please fill out the following questionnaire. These experiences may impact how a child responds to stress, attention, decision-making, and learning and having this information will help guide your therapist’s plan of care and approach to therapy.
Add in total for each section and write the number in the corresponding box.
Section 1. At any point since your child was born:
Your child’s parents or guardians divorced or separated
Your child lived with a household member who served time in jail or prison
Your child lived with a household member who was depressed, mentally ill, or attempted suicide
Your child saw or heard household members hurt or threaten each other
A household member swore at, insulted, humiliated, or put down your child in a way that scared your child or your child felt scared they may be physically hurt
More than once, your child went without food, clothing, a place to live, or had no one to protect them
Someone pushed, grabbed, slapped, or threw something at your child or your child was hit so hard that your child was injured or had marks
Your child lived with someone who had a problem with drinking or using drugs
Your child often felt unsupported, unloved, or unprotected
Section 2. At any point since your child was born:
Your child was in foster care
Your child experienced harassment or bullying at school
Your child lived with a parent or guardian who died
Your child was separated from their primary caregiver through deportation or immigration
Your child had a serious medical procedure or life-threatening illness
Your child often saw or heard violence in the neighborhood or in their school
Your child was often treated badly because of race, sexual orientation, place of birth, disability, or religion
HIPAA PRIVACY POLICY
Your privacy matters: In 1996, Congress passed legislation to provide continuity of coverage when individuals switch health plans and to ensure the security and privacy of protected health information.
The Pediatric Therapy Clinic, Inc. has always been committed to protecting individuals' health information and will continue its commitment by ensuring compliance with the Health Insurance Portability and Accountability Act (HIPAA) privacy requirements.
This rule - the first federal rule to protect the privacy of health information -establishes basic national privacy standards for healthcare providers, health plans and healthcare clearinghouses to follow, in order to protect patients and encourage them to seek needed care. The HIP AA Privacy Rule grants healthcare consumers several rights regarding their privacy and protected health information. The Pediatric Therapy Clinic, Inc. has instituted documents, policies and procedures that address
these rights.
These include the right to: Receive the Pediatric Therapy Clinic's Inc. Written Notice of Privacy Practices, which details individual rights and provides examples about how health information is used for treatment, payment, and health care operations.
Request a restriction on specific uses and disclosures of protected health information. Receive confidential communications of health information.
Access, inspect and copy protected health information.
Request amendment and/or correction of protected health information.
Receive an accounting of disclosures of protected health information.
File a complaint with the Pediatric Therapy Clinic, Inc. as well as with the DHHS
What The Pediatric Therapy Clinic, Inc. is doing to protect your privacy: Pediatric Therapy Clinic, Inc. has taken a very active role in preparing for this legislation to ensure that your right to protected health information is recognized.
We have appointed a Privacy Officer. She is responsible for helping Pediatric Therapy Clinic, Inc. reach its privacy goals and also to address concerns from patients, family and staff relating to confidentiality issues.
We have prepared a Notice of Privacy Practices for you. This document tells you what we do with your health information and what your rights are. This document is available during registration or you may request your own by calling (406) 259-1680 and asking for a copy of the Notice of Privacy Practices.
Privacy Fact Sheets available to consumers: The Department of Health and Human Services (HHS) Office for Civil Rights (OCR) privacy listserv offers two fact sheets available on its Web site.
The first, "Privacy and Your Health Information, "provides a general overview of the HIPAA privacy rule and individual rights associated with the rule. The second, "Your Health Information Privacy Rights," focuses on each of the privacy rights included under the rule.
Both sheets can be obtained from the OCR Web site at https://www.hhs.gov/ocr/hipaa/
Patients Rights and Responsibilities
o Be treated with respect to and have the right to privacy
o Receive care that is considerate and respects my personal values and belief system
o Personal privacy and confidentiality of information
o Reasonable access to care, regardless of my race, religion, gender, ethnicity, age or disability
o Participate in an informed way in the decision making process, regarding treatment planning and implementation of services, from referral to discharge
o Discuss with treating professionals appropriate or medically necessary treatment options for my child's condition, regardless of cost or benefit coverage
o Services provided in the most appropriate and least restrictive manner
o Freedom from unnecessary restraint or drugs
o Receive assessment and treatment information in an understandable manner
o Accept or refuse services and the right to refuse to participate in research programs and projects
o The right to file a grievance regarding violations of your human rights and receive a timely response
o The right to individualized programming and sensitive treatment practices
o Request information regarding the qualifications of staff members who provide your services
o Transition services as necessary and appropriate
Financial Policy and Consent
o It is required that all patients be accompanied by a parent or legal guardian at the time of the initial visit.
o We require a 24-HOUR ADVANCED NOTICE FOR ALL CANCELLATIONS.
o Three no-show appointments over a three month period will result in a discontinuation of services.
o If you arrive late for your scheduled appointment time, you may be required to reschedule so that other patients are not inconvenienced.
o Co-payments, if dictated by your insurance policy, are due at the time of service.
o Patients will be responsible for the remained of their bill not paid by insurance.
o Payments must be made within 30 days of receipt of statement.
o An 18% interest may be applied to all payments that are not made within 30 days of statement.
o Statements not paid within 30 days will result in an immediate discharge from therapy.
o Statements not paid within 90 days are subject to collections.
o All checks returned to us for non-sufficient funds will result in a $35 processing fee. The original check amount plus the processing fee must be paid at your next appointment or within 10 days.
o I understand that Pediatric Therapy Clinic has the right to bill as private pay if the passport referral is not given for the services rendered by the Passport PCP listed with Montana Medicaid.
I understand that I am responsible for:
o Providing (to the extent possible) the treating therapist(s) with information needed in order to receive appropriate care
o Following plans and instructions for care that I have agreed upon with the treating therapist(s)
o Understanding my health problems and participating, to the degree possible, in developing, with the treating therapist(s), mutually agreed upon treatment goals
o Payment of the balance of treatment services not covered 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 THE PEDIATRIC THERAPY CLINIC, INC.
I HAVE READ AND UNDERSTAND THE PATIENT RIGHTS AND RESPONSIBILITIES.
Authorization to Release Information
I understand this release is voluntary and applies to all programs and services operated under the auspices of Pediatric Therapy Clinic, INC. I understand that my personally identifiable information (PII) may be protected by the federal rules for privacy in the Family Educational Rights and Privacy Act (FERPA), the Health Insurance Portability and Accountability Act (HIPPA), and/or other applicable state or federal law and regulations. I understand that my PII may be subject to redisclosure by the recipient without specific written consent of the person to whom it pertains, or as otherwise permitted. I also understand that the recipient may not condition treatment, payment, enrollment or eligibility on whether I sign this form, except for certain eligibility or enrollment determinations.
I understand that I may revoke this authorization at any time by notifying Pediatric Therapy Clinic, Inc. in writing but if I do, it will not have any effect on any actions taken before receipt of the revocation.
E-Signature
Please sign electronically below.
Click submit and you hereby give consent to sign this document electronically.
