Demographics and Medical History Form

CHILD'S EVALUATION AND TREATMENT HISTORY:

Please tell us all doctors or specialists involved in your child's care:

Please check any/all developmental, medical, mental health or behavioral diagnoses your child has received. Please include details on diagnosing physician and age of diagnosis below the checkboxes

Diagnostic tests: (dates and results, if known)

Please check any special tests, procedures, and/or hospitalizations since birth (MRI, EEG)

Please list all agencies and intervention services from the past and present, as well as additional details for frequency and specific agencies regarding anyone your child is currently seeing:

EDUCATIONAL HISTORY

(If Yes, please remember to bring a copy with you to their evaluation)

Please ensure that if your child is receiving any school-based therapies that you include those in the above chart for all therapy types and frequencies.

BIRTH HISTORY

DEVELOPMENTAL HISTORY: (*These can vary within normal range)

Please specify the ages completed for each milestone

Please list all medication your child takes:

DAILY ROUTINES:

How does your child play with siblings or other children their own age?

Safety concerns we should be aware of: 

Pediatric Advanced Therapy is committed to providing you and your family with the best possible care.  Please understand that our office policies are in place to ensure that we are able to continue to provide excellent care to all of our patients, and services that are affordable.
 
As a courtesy for our patients’ families, we will call your insurance carrier before treatment begins to verify coverage and benefits.  The information we obtain is not a guarantee of payment; your insurance will process the claims based on your specific policy, medical necessity, and any exclusions or limitations attached to your plan. It is important that you understand that you will be responsible for any charges not covered by your insurance plan including—but not limited to—deductible, co-insurance, and co-payments.  In addition, many insurance plans have a maximum number of therapy visits covered per year, with anything in addition being the responsibility of the patient.  It is your responsibility to track the number of visits you have used. We do have a reduced, self-pay rate that we will apply if/when this occurs.  
The privacy of your medical information is important to us. We understand that your medical information is personal, and we are committed to protecting it. We create a record of the services you receive at Pediatric Advanced Therapy. We are required by law to inform you of the “class of persons” who will have access to your medical information in order to carry out their job duties. This would include our therapy staff, administrative & billing staff, and management. We may use and disclose your medical information for the purpose of treatment, payment, and health care operation activities.

Insurance payments and patient responsibilities may increase or decrease your balance depending on when your insurance processes your claims. Insurance estimates and notifications about billing will be communicated through our Patient Portal.

All clients are required to have a card on file with Pediatric Advanced Therapy. Statements are generated on the 1st and the 15th of each month. The total statement balance that has not been paid by the 10th and 25th of each month will be auto drafted from the card on file to cover any current balances plus any past due balance. Payments will be processed the day after any holiday or closure. No payment will be processed if there is no balance at the time of auto draft. Our billing team will manually review all account balances over $200 to ensure accuracy.
 
All payment policies will remain in effect until all pending claims have been processed with insurance and insurance has determined patient responsibility and/or any appeals with insurance have been satisfied.

Disputes with how insurance has processed a claim will be the responsibility of the member to appeal. Pediatric Advanced Therapy will not hold or suspend payments during a member appeal with their insurance. If the provider has filed an appeal with insurance, the claim will remain insurance responsibility until the appeal has been satisfied, at that point, the balance insurance deems patient responsibility will be processed.

If any client has a refund due at the termination of services, after all pending claims have been processed, a refund will be issued through the original source of payment. Refund times vary depending on your financial institution.

If payment is declined or returned, an alternative payment method must be provided within 48 hours. If failure to provide an alternative payment method is not provided within 7 days or payment is declined for two consecutive payments, the payment plan will be terminated, and the patient will be responsible for the full balance in accordance with our payment policies. The client will be removed from permanent scheduled sessions if there is not an active and valid card on file.
 
We are prepared to help you understand your insurance coverage and answer any questions you may have about the payment plan policy. Don’t hesitate to ask questions. You can reach our billing department by calling 704-799-6824 or emailing billing@patkids.com

I have read and agree to the financial and payment policy at Pediatric Advanced Therapy and consent to payment of my balance in full via auto-draft with the card that I place on file.

I authorize direct payment of medical benefits to Pediatric Advanced Therapy. The benefits referred to herein would be payable to me (policy holder) if I did not make assignment and include Major Medical Insurance. I understand that I am personally responsible to Pediatric Advanced Therapy for any and all payments not covered by the insurance companies, such as co-payments, co-insurance, deductibles and denied services. All payments are due at the time of service.
 
The attending therapist is authorized to release any medical information required in the administering of applications for financial coverage for service required. He/she may also send the results of the evaluation and recommendations to my referring physician for coordination and continuity of care. I have carefully completed this form and to the best of my knowledge it does not contain any false, incomplete or misleading information.

POLICIES & PROCEDURES reviewed  5/17/2024                                                                                                                                        

Evaluations
All evaluations usually last for one hour. It is the responsibility of the parent/guardian to bring all pertinent information to the evaluation. This includes your completed paperwork, insurance card, Medicaid card, and any medical history and/or past evaluations your child has received. You will need to be present for the first 20 minutes of the evaluation so that the therapist can ask you some questions. The remainder of the evaluation time will include clinical observation and in most cases, standardized testing. For liability reasons, we can only allow the children who are being treated into the gym and therapy rooms. Siblings MUST stay in the lobby, NO EXCEPTIONS.
 
Treatment Sessions
Counseling, Occupational and Physical Therapy sessions last for 50 minutes. Following the session is a 10-minute window to discuss your child’s therapy with the therapist. It is mandatory that you are in the lobby during this 10-minute time frame. Please have your child use the restroom prior to the treatment session. Speech Therapy evaluations last for one hour and treatment sessions are 30 minutes.
 
If you leave the clinic while your child is in session, you MUST leave a phone number where you can be reached. You must return to the clinic before your child’s session ends. This allows time for the therapist to speak with you regarding your child’s treatment and progress, and also keeps the next client’s session on schedule.
 
Video:
In all of our locations you will see cameras in the lobby. These are not recording any data, but rather a live feed onto secure accounts where therapists are able to see if their clients are in the building. You may also notice other cameras in some treatment spaces. These are also not recording, but live feeds for supervision of clients with virtual supervisors who may be at another site. Since this is secure-access live-feed and only accessible to relevant clinicians in the company, it is no different than a clinician being in the building observing clients, and they may see children from other disciplines in the general area. We just want you to be aware what they are for and ensure that your child would not be recorded in any manner without your consent.
 
Special Conditions:
Please note: If your child has any of the following conditions it is mandatory that you remain on the premises during his or her therapy session. These conditions include: Seizures, severe allergies, significant behavioral issues, and any condition that requires medicine to be controlled. This is for the safety of your child and the protection of our staff. If you arrive late for your session, your appointment will still end at the original end time.
 
Cancellations:
Please try to give 24-hour notice when cancelling an appointment. (Occasional last minute emergencies are understood.) If you call after hours, please leave a message on our answering machine. Frequently cancelled appointments (3 within a 6 week period) will be basis for removal from our permanent schedule. When we establish a treatment plan for your child, we base our goals on the child having consistency. If your child misses appointments, they will not meet their goals as quickly, and your child will have to be enrolled in therapy for a longer period of time. The success of our treatment sessions depends on consistency. Medicaid and insurance companies require us to report attendance and show progress towards goals. In the event that you do have to cancel, we strongly encourage you to schedule a make-up appointment, even if it is with another therapist. It is often beneficial for your child when another therapist treats him or her because it gives the regular attending therapist another opinion or ideas for your child. Our staff is always in close communication with each other.
 
In the event that the therapist needs to cancel, we will reschedule your child with another therapist for continuity of treatment.
 
Failure to cancel or to appear for an appointment is considered a “NO SHOW.” We will charge a $25.00 fee for “NO SHOW” appointments. After 3 “NO SHOW” appointments or late cancellations your appointment spot will be terminated. Please see our attached cancellation policy for further details.

Please note: It is mandatory that you remain on the premises for the duration of sessions if your child has severe seizures, severe allergies, requiring epi-pen, significant behavioral issues. This is for the safety of your child and the protection of our staff.

As a convenience to me, I hereby request that P.A.T. communicate with me regarding my treatment by P.A.T. via electronic communications (e-mail or text message). I understand that this means P.A.T. and/or my treating providers will transmit my protected health information such as information about my appointments, diagnosis, medications, progress and other individually identifiable information about my treatment to me via electronic communications.

I understand there are risks inherent in the electronic transmission of information by e-mail, on the internet, via text message, or otherwise, and that such communications may be lost, delayed, intercepted, corrupted or otherwise altered, rendered incomplete or fail to be delivered. I further understand that any protected health information transmitted via electronic communications pursuant to this authorization will not be encrypted. As the electronic transmission of information cannot be guaranteed to be secure or error-free and its confidentiality may be vulnerable to access by unauthorized third parties, P.A.T. shall not have any responsibility or liability with respect to any error, omission, claim or loss arising from or in connection with the electronic communication of information by P.A.T. to me.

After being provided notice of the risks inherent in use of electronic communications, I hereby expressly authorize P.A.T. to communicate electronically with me, which will include the transmission of my protected health information electronically. I understand that in the event I no longer wish to receive electronic communications from P.A.T., I may revoke this authorization by providing written notice to P.A.T. at 134 Infield Court, Mooresville, NC 28117 or fax at (704) 799-6825.

I agree that P.A.T. may communicate with me electronically unless and until I revoke this authorization by submitting notice to P.A.T. in writing. This authorization does not allow for electronic transmission of my protected health information to third parties and I understand I must execute a separate authorization for my protected health information to be disclosed to third parties.

I hereby authorize the transmission of my protected health information electronically as described above.

Pediatric Advanced Therapy will be collecting video and photograph records of your child’s performance during therapy sessions for their electronic medical record. I understand and consent, as this will benefit their therapy program.

Additional Options:
I consent for:

PURPOSE: This notice describes how medical information about you may be used and disclosed and how you can obtain access to this information. Please read carefully.
The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the services you receive at Pediatric Advanced Therapy. We need this record to provide you with quality care and to comply with certain legal requirements. We are required by law to maintain the privacy of protected health information. This notice will tell you about the ways we may use and share medical information about you.

As a general rule, Pediatric Advanced Therapy will not release any information to outside providers without your written consent. We are a group practice with multiple disciplines. We can consult with our associates when clinically advisable to improve overall patient care.

USE AND DISCLOSURE OF MEDICAL INFORMATION: Following is a list of the different ways we are permitted to use and disclose medical information. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written information you provide may be revoked at any time by writing to us.

·       FOR TREATMENT: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students or other people who are taking care of you. We may also share medical information about you to your other health care providers to assist them in treating you. We may discuss medical information about your child with interdisciplinary staff at Pediatric Advanced Therapy to improve their overall care.

·       FOR PAYMENT: We may use and disclose your medical information for payment purposes.

·       FOR HEALTH CARE OPERATIONS: We may use and disclose your medical information for our health care operations. This might include measuring and improving quality, evaluating the performance of employees, conducting training programs and getting the accreditation, certificates, licenses and credentials we need to serve you.

·       ADDITIONAL USES AND DISCLOSURES: In addition to using and disclosing your medical information for treatment, payment, and health care operations, we may use and disclose medical information for the following purposes.

·       DECEASED PATIENTS: We may disclose PHI regarding deceased patients as mandated by state of law , or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person's estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.

·       MEDICAL EMERGENCIES: We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.

·       FAMILY Involvement in Care: We may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.

·       VERBAL PERMISSION: We may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

•       WITH AUTHORIZATION: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization.

The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record;

(ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications;

(iii) disclosures that constitute a sale of PHI; and

(iv) other uses and disclosures not described in this Notice of Privacy Practices.
 
Court orders and Judicial and Administrative proceedings: We may disclose medical information in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Under limited circumstances, such as court order, warrant, or grand jury subpoena, we may share your medical information with law enforcement officials. We may share limited information with a law enforcement official concerning the medical information of a suspect, fugitive, material witness, crime victim or missing person.

Public Health Activities: As required by law, we may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury or disability, including child abuse or neglect. We may also disclose your medical information to persons subject to jurisdiction of the Food and Drug Administration for purpose of reporting adverse events associated with product defects or problems, to enable product recalls, repairs or replacements, to track products, or to conduct activities required by the Food and Drug Administration. We may also, when we are authorized by law to do so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition.

Victims of Abuse, Neglect, or Domestic Violence: We may disclose medical information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or violence or the possible victim of other crimes. We may share your medical information if it is necessary to prevent a serious threat to your health or safety or the health and safety of others. We may also share medical information when necessary to help law enforcement officials capture a person who admitted to being a part of a crime or has escaped from legal custody. If a therapist suspects that child abuse or neglect has occurred, the law requires that it be reported to the proper authorities. Child abuse includes sexual exploitation and physical or mental injuries that result in impaired functioning. Child neglect includes failure to provide for the basic needs of the child (including medical care) and inappropriate discipline.

Health Oversight Committees: We may disclose medical information to an agency providing health over sight for oversight activities authorized by law, including audits, civil, administrative, or criminal investigations or proceedings, inspections, licensure or disciplinary actions, or other authorized activities.

YOUR INDIVIDUAL RIGHTS:
You have a right to:

·       Look at or receive copies of your medical information.
·       Receive a list of all the times we or our business associates shared your medical information for purposes other than treatment, payment and health care operations and other specified expectations.
·       Receive your own confidential health information by alternative means or alternative locations.
·       Request that we place additional restrictions on our use or disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the case of an emergency).
·       Request that we change your medical information. We may deny your request if we did not create the information you want changed or for certain other reasons. If we deny your request, we will provide you with an explanation. You may respond with a statement of disagreement that will be added to the information you want changed. If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include any changes in any future sharing of that information.
·       Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
·       Right to Request Confidential Communication. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. We will not ask you for an explanation of why you are making the request.
·       Breach Notification. If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself. Right to a Copy of this Notice. You have the right to a copy of this notice.
 
In each case, you must make your request in writing to the Privacy Officer at Pediatric Advanced Therapy.

QUESTIONS AND COMPLAINTS: If you have any questions about this notice or if you think that we have violated your privacy rights, please contact us. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services. This complaint must be filed within 180 days of when the complainant knew or should have known that the act had occurred. The secretary may waive this 180 day time limit if good cause is shown.

This notice is effective for one year from signature date.