NEW PATIENT INTAKE FORM

INSURANCE INFORMATION (please fill out ALL areas)

Please initial the following statement:

 I DO NOT HAVE ANY OTHER INSURANCE COVERAGE FROM ANY OTHER SOURCE OTHER THAN THE ABOVE MENTIONED."

EMERGENCY MEDICAL RELEASE

In the event medical attention is required for your child while on the premises of All For Kids, LLC, we need your authorization to implement treatment. Please read and sign the statement below. 

I give my permission for All For Kids, LLC to contact emergency personnel in the event of a medical emergency.

Please initial the following OPTIONAL statements:

Please initial the following statement(s):

 

Teletherapy Records (REQUIRED; please initial)

By telehealth law we are required to ask if you would like for AFK to send a copy of EACH teletherapy session note to your child's primary care physician. For in-person therapy, we do not send your child's session notes unless requested. Would you like to opt out of sending each note or would you like us to fax each note after every session?

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (HIPAA):

I acknowledged that I have viewed, read, and understand the HIPAA Policy (attached at the end of this packet) and have been informed of my rights as a patient's parent/guardian.

**If your child has an Individualized Education Plan (IEP), neuropsychological evaluation, or any additional relevant reports, please bring a copy for your therapist to review. **

 

HISTORY FORM

Please answer the questions to the best of your ability and in as much detail as possible. Please add any information that you feel is important but is not covered on this form.

General History

DEVELOPMENTAL HISTORY

Please indicate at what age each major milestone was reached:

SOCIAL HISTORY AND LIVING SITUATION

If your child was adopted, please answer the following questions:

PATIENT AGREEMENT

All For Kids Pediatric Therapy, LLC offers Physical Therapy, Occupational Therapy, and Speech-Language Pathology services for patients referred to our practice. We are a licensed provider who develops individualized treatment plans to identify the services that will best suit your child's therapy needs. We will also work with your primary care practitioner to coordinate your care.

Following the initial assessment visit(s), we develop a specific plan of care (POC) for review and approval by your child's referring provider. Once your child's referring provider signs the (POC), we can begin working with your family to improve your child's condition. We are pleased to serve your Physical Therapy, Occupational Therapy, and/or Speech-Language Pathology needs and encourage your feedback to alert us to anything we can do to provide your child the highest quality of care.

We require certain information from each patient in order to begin providing care. The attached forms need to be completed in order for us to begin serving your child as our patient. Please do your best to complete all the information. If certain information does not apply to your child, please indicate that by noting "N/A" ("Not Applicable") so that we know that you did not overlook anything.

Each healthcare insurance payor has different guidelines for allowing coverage of Physical Therapy, Occupational Therapy, and/or Speech-Language Pathology services. It is helpful if you let us know your healthcare payor when starting service so that we may find out if prior authorizations are needed. If your child is a Medicaid beneficiary, please ask your primary care provider to send us a referral for your initial assessment to fulfill Medicaid requirements. If your healthcare insurance payor does not cover Physical Therapy, Occupational Therapy, and/or Speech-Language Pathology services, you are welcome to make self pay arrangements for the usual and customary pricing of our services.

ALASKA MEDICAID RECIPIENTS:

Alaska Medicaid requires that a physician, physician assistant, or advanced nurse practitioner refer you to our practice before we can perform an initial assessment on you. After we have completed your initial assessment, we develop an individualized POC to meet your specific therapy goals.

Your primary care practitioner will need to review and approve your POC, and then return it to our practice before we can begin your treatment.

MEDICAID & PRIVATE INSURANCE
CO-PAYMENTS, DEDUCTIBLES, AND NON-COVERED SERVICE

Private insurance companies may have limits on the amount of Physical Therapy, Occupational Therapy, and/or Speech-Language Pathology services covered. Once you have exceeded the financial limit of your benefits and you do not have additional healthcare coverage, you are responsible for the payment of your child's services. Additionally, private healthcare insurance payors have deductibles and co-payments for physical therapy, occupational therapy, and/or speech language pathology services that are the responsibility of the patient.

While this practice will not discontinue your child's services for financial hardships, it is expected that patients pay at the time of service and/or set up payment arrangements.

COLLECTION OF PAST DUE ACCOUNTS

We communicate with our patients' parents/guardians to resolve past due accounts in all cases. If we cannot reach a patient's parent/guardian following the return of undeliverable mail, or if a patient payment agreement cannot be made or paid as agreed, we are forced to use the services of a professional collection agency. Once an account is placed with a collection agency, we cannot take the account back. Please let us know when or if your patient contact information changes so that we can always reach you, if needed, to discuss past due accounts.

FINANCIAL AGREEMENT

New patients approved for Physical Therapy, Occupational Therapy, and/or Speech-Language Pathology services are responsible for any and all charges not paid for by healthcare insurance payors (Medicaid, private health insurance carriers, etc By signing this patient agreement, you are acknowledging that you understand this condition of service and commit to promptly paying All For Kids Pediatric Therapy for the services we provide to you, our valued customer. Following the receipt of your monthly patient statement, please contact our practice to make payment arrangements. We accept cash, personal checks, money orders, and credit cards (VISA, MasterCard, and Discover Card); we also make credit card pre-payment arrangements for anticipated monthly patient balances. We also are willing to make reasonable payment arrangements to keep your account current. Please contact our Billing Office at (907) 345-0050.

QUALITY ASSURANCE & COMPLAINT RESOLUTION

Should you or your child's caregiver experience a situation that requires the attention and resolution of a Supervisor and/or Manager, please contact our practice either in writing or by phone at (907) 345-0050. A member of our management team will interact with you to reach a resolution of any identified situation where our quality of service has been compromised. We use such situations to alert us to improvements we can make to better serve all our patients.

PATIENT STATEMENT OF AGREEMENT

My signature below signifies that I have read and understand this patient agreement for All For Kids Pediatric Therapy, LLC to provide me Physical Therapy, Occupational Therapy, and/or Speech-Language Pathology services. I agree to the terms in this patient agreement and intend to comply with them to the best of my ability. I understand that if I fail to follow the terms of this agreement, | could be discharged from service.

FINANCIAL POLICY

Payment, co-payment, deductibles, and co-insurance for services are due each visit for charges incurred up through your last visit. We accept cash, checks, VISA, MasterCard, and Discover Card. Please understand that you are financially responsible for all charges, whether or not they are paid by insurance and that failure to abide by the financial policy will result in prompt removal from the schedule.

Please read carefully and initial each statement:

I hereby understand the above financial policy and agree to abide by it.

CREDIT CARD AUTHORIZATION

My signature below indicates I agree to the terms above and authorize All For Kids to charge my credit/debit card as agreed upon above. I understand that my information will be saved in a secure online system for future transactions on my account and that this authorization will remain in effect until I cancel it in writing. I certify that I am the authorized user of the provided card and will not dispute these scheduled transactions; so long as the transactions correspond to the terms indicated in this authorized form.

As a courtesy, please call our office within 24 hours of a scheduled appointment if you need to cancel or reschedule that appointment. For Monday morning appointments, our office appreciates being notified no later than Friday noontime. If therapy needs to be canceled for an extended length of time (for example, due to vacation, insurance problem, etc.), management will discuss and approve holds on a case-by-case basis.

Please read carefully and initial each statement:

I hereby understand the above cancellation policy and agree to abide by it.

CLINIC ETIQUETTE

Once again, we welcome you to All for Kids Pediatric Therapy. We are honored that you have chosen our clinic to meet the needs of your child and your family. We continually try to create a space and an atmosphere that is true to our name - fun and inviting for kids and their families. We hope that you are comfortable here and always feel welcome. Please know that you can approach us with any comments or concerns regarding our space and how it is used. In order to make All for Kids a comfortable and safe place for all of our families and our staff, we ask that families follow our clinic etiquette plan. Please read and become familiar with the following expectations.

Please adhere to the following steps when coming to therapy:

If you are a new patient, please come in and check in with the front desk and wait inside for your therapist.

If you are an existing patient, please wait in your car and call the front desk at 907-345-0050 to check in. After you call to check in, walk your child into the building no earlier than 5 minutes before their appointment and wait in our transition zone. Help your child remove their shoes and coat to have them ready for therapy. Once your child transitions to the therapist, return to your car to wait if you are not joining the session.

Come back into the building to pick up your child no earlier than 5 minutes before the end of the appointment time. Parents/caregivers must be timely to pick up in order to avoid late pickups, provide adequate time for session debriefing, and to help our therapists be on time to their next client.

Please note the following clinic etiquette expectations:

Please make arrangements to attend your child's therapy session when requested by the therapist. We also welcome parent requests to join treatment sessions. Active parent participation in the therapy process is critical for progress and carryover of new skills. Let your child's therapist know if you would like to participate in a session. If siblings will be observing and/or participating, it should be with permission from the therapist.

If parents are in attendance at sessions, please remove your shoes per our clinic policy. There is space near the front desk window to leave shoes as well as coats/jackets.

Do not enter the treatment space without a clinic escort.

Accompany all younger children and those needing assistance or supervision to the restroom; this includes using the restroom for hand washing.

If you have children in diapers or pull-ups, please bring a diaper bag for your therapist and/or be prepared to change your child if necessary.

We discourage bringing toys from home to treatment sessions unless your therapist requests them or gives permission to bring them. Your therapist will choose toys from our clinic with a specific therapeutic purpose.

If you are observing your child's treatment session, remain in the same room as your child and their therapist. In order to protect the confidentiality of all children in our clinic, please do not leave the treatment room unless accompanied by your therapist or exiting the building.

Please keep cell phone and tablet use to a minimum in treatment areas and place phones on vibrate or silent. Photos and videos are prohibited in shared treatment spaces.

Please be mindful of the content discussed in your conversations (phone or in-person) or viewed on your electronic devices while in the clinic. Please only discuss topics or select websites, videos, music, etc. which are appropriate to discuss/view in the presence of children.

Please do not ask therapists about other clients or families at the clinic. In order to comply with HIPAA, we cannot answer these questions.

Be respectful of the 'end of session' time. Your therapist typically has less than 5 minutes to talk to you about the session. In most cases, there is another family waiting to begin therapy. If you need additional time to discuss a concern, ask questions, or problem-solve treatment activities, please join your child's session or arrange for an alternative time to discuss those topics with your child's therapist.

Do not send your child to therapy if they have a fever or other contagious illness not managed by medication and/or cleared by a doctor (e.g., pink eye, lice, active vomiting, hand foot and mouth disease Keep your child home until they are fever-free for 24 hours without medication and symptoms are improving. If you need to cancel due to illness, rescheduling your appointment whenever possible is encouraged to maintain your child's progress and attendance. For any other questions about AFK's illness policy, please contact the front desk.

As your team of therapists, you can expect us to:

Begin and end your appointments in a timely manner.

Inform you of the goals targeted and the progress made during each session.

Provide strategies and ways for you to address goals at home to increase carryover.

Assist you in any way we can, such as brainstorming ideas to help make your family's life easier at home or talking with school therapists, etc.

Keep anything you share with us confidential.

Provide the best therapy we possibly can.

Receive courteous and friendly help when scheduling appointments or dealing with billing questions.

If you have any questions about the above information, please do not hesitate to ask us. We are here to help you!

I have read and understand the above Clinic Etiquette and agree to abide by it.

PERSONS SERVED

Children age from birth to adolescence. New clients 14-18 years of age are seen on a case by case basis.

Medical Acuity & Medical Stability:

Children must be healthy and cleared for treatment by their physician. Children may not attend therapy if they have potentially contagious illnesses, including but not limited to:

• Fever of 100.4 or greater
• Pink eye
• Vomiting and/or diarrhea
• Hand-foot-mouth disease
• Lice

Our Setting:

Therapy services are provided between the hours of 7 AM and 6 PM, Monday through Friday, at our clinic located at 6927 Old Seward Highway, Suite 100. Therapy is provided in an outpatient setting at the YMCA Dimond Pool for aquatic therapy.

Our clinic prioritizes movement and play alongside learning, which means sessions will often be active and play-based, and may involve activities with inherent risks (e.g., climbing, jumping, or other physical movement Therapists monitor all session activities to ensure client safety and provide appropriate guidance and support throughout the session.

Admission Criteria:

Your child's evaluation with your therapist will determine the need for therapeutic intervention, typically on a weekly, ongoing basis until criteria for discharge is achieved. Your child may be referred to another agency or for a different service depending on the recommendations of the evaluation and our clinic's ability to adequately meet their needs.

Your Therapist:

A therapeutic match with your therapist is important. If a personality conflict arises that interferes with the therapeutic match between your child/family, please speak with your therapist directly or a member of the management team to inquire about switching therapists.

When your therapist is out of the office, your child may have coverage with a substitute therapist. Substitute therapists make every effort to make sessions as fun and productive as when your child sees their regular therapist. These visits bring a positive opportunity for your child to practice their skills with a new person and bring a different perspective to your child's treatment.

Discharge Criteria:

AFK may discharge a client for the following reasons:

• Client has completed the plan of care and no further concerns are identified
• Client is 18 years of age
• Client no longer demonstrates a need for intervention
• Client has plateaued and is not benefitting from continued services
• Client is not meeting financial responsibilities to AFK
• Client is not meeting the required attendance
• At the request of the caregiver
• At the discretion of AFK management for any other reasons (e.g., safety within the clinic)

NOTICE OF PRIVACY PRACTICES:

CLICK HERE to read the privacy practices.