advancetherapymn

Which location?*

Lino LakesWhite Bear Lake
Select all that apply:*

OccupationalPhysicalSpeech/Language
CLIENT INFORMATION:
CLIENT NAME*
DOB*

MonthDayYear
SS#*
STREET ADDRESS*
CITY*
STATE*
ZIP*
NAME OF PHYSICIAN SUPPORTING THIS RECOMMENDATION (OR PRIMARY CARE PHYSICIAN):
NAME*
PHONE*
CLINIC*
FAX*
PARENTS/LEGAL GUARDIANS:
PARENT/GUARDIAN #1*
MARITAL STATUS*

MSDW
DOB*

MonthDayYear
SS#*
RELATION TO CLIENT*
STREET ADDRESS (If different from above)
CITY*
STATE*
ZIP*
BEST PHONE*
OTHER PHONE?
BEST EMAIL*
example@example.com
PARENT/GUARDIAN #2
DOB

MonthDayYear
SS#
RELATION TO PATIENT
ADDRESS (If different from above)
BEST PHONE
OTHER PHONE
*WHO IS THE BEST PERSON TO CONTACT RE: SCHEDULING?*
INSURANCE:
- PRIMARY INSURANCE COMPANY
NAME OF INSURANCE*
GROUP #*
ID #*
POLICY HOLDER*
EMPLOYER (if applicable)*
DOB (If not listed on first page)

MonthDayYear
Date
SS# (If not listed on first page)
- SECONDARY INSURANCE COMPANY
GROUP #
ID #
POLICY HOLDER
EMPLOYER (if applicable)
DOB (If not listed on first page)

MonthDayYear
Date
SS# (If not listed on first page)
AUTHORIZATIONS

OTHER CONTACTS:
Please list other individuals who are involved in this client’s/patient’s care, with which you authorize Advance Therapy to discuss the child’s treatment. (Spouse, step parent, grandparent, personal care attendant)
NAME #1*
EMERGENCY CONTACT*

YesNo
RELATION TO PATIENT*
PHONE #1*
PHONE #2
NAME #2
EMERGENCY CONTACT

YesNo
RELATION TO PATIENT
PHONE #1
PHONE #2
EMAIL COMMUNICATION:

Occasionally it is helpful to communicate general information about the services my child receives at Advance Therapy through email. As I read in Advance Therapy’s Notice of Privacy Practices, it is important to keep some guidelines in place when communicating through email.

I am providing the following email address and will let Advance Therapy know of any changes to this address:
SECURE EMAIL ADDRESS*
example@example.com
I, __________________ agree to keep this email account secure and not send identifying information (i.e. client names, etc) to staff at Advance Therapy in my communications. When emailing I will keep the subject line general, not use full names and not attach reports (i.e. IEPs, etc) with identifying information when emailing to staff at Advance Therapy. I know Advance Therapy is unable to email any therapy reports.*
NAME
Client/Parent/Guardian signature*

Clear
Date*

MonthDayYear
Date
PRIVACY/PAYMENT:
- I authorize Advance Therapy to provide information concerning the treatment plan of this patient listed above to insurance carriers, physicians, therapists and other personnel who are involved in the treatment and care of the client/patient.
- I authorize payment of any medical benefits to Advance Therapy.
- I certify that the above information is correct and that I am responsible for payment of services rendered.
- I permit of copy of this to be used in place of the original.
Client/Parent/Guardian signature*

Clear
Date*

MonthDayYear
Date
How did you hear about us?*

DoctorInternet SearchFriendSchoolType Insurance
INITIAL EVALUATION QUESTIONNAIRE
Date

MonthDayYear
Date
CHILDS NAME
DOB

MonthDayYear
PRIMARY LANGUAGE SPOKEN AT HOME
INTERPRETER REQUESTED?

YesNo
DID ANYONE HELP YOU FILL OUT THESE FORMS?

YesNo
DIAGNOSIS (if any)
PARENT/CAREGIVER NAME(s)
Reason for evaluation:
Parental Concerns
Recommendations from other professionals
*Please answer the following questions to the best of your ability.
Significant childhood illnesses or injuries?

YesNo
If yes, please describe:
Has hearing been evaluated?

YesNo
If yes, when?
PE Tubes?

YesNo
If yes, when?
Has vision been evaluated?

YesNo
If yes, does your child wear glasses?

YesNo
Environmental or food allergies?

YesNo
If yes, please list:
Currently taking any medications?

YesNo
If yes, please list:
Any dietary restrictions?

YesNo
If yes, please list:
How would you describe your child at present: (include behavior, mood, ability to learn new things, attention, ability to calm, strengths, etc.)
Describe your child's likes and dislikes:
How does your child communicate? (Verbal, gesture, pictures, sign, AAC)
If school age, what school does your child attend?
Does your child have an IEP or IFSP? If yes, please attach or briefly describe his/her goals:
If yes, when was last evaluation?

MonthDayYear
Is there a family history of any related medical (physical or emotional) conditions?
Do any of your child’s siblings receive therapy services?
Has your child previously received or is your child currently receiving therapy? If so, where?
Please list your desired goals: (e.g. in the next several months I would like my child to...)
Additional comments, questions or concerns?
*When treatment is recommended, we always want to schedule appointments on days and times that work well for you. Evening and weekend appointments are most popular.
Please describe your child’s weekly school/daycare schedule and your current availability. Thank you for your flexibility!
CONSENT TO RELEASE INFORMATION
I authorize Advance Therapy staff to share information regarding my child with the following people/organizations: (school, social worker, ABA therapist, PCA, etc.)
1. Name and/or Organization
1. Phone and/or FAX
2. Name and/or Organization
2. Phone and/or FAX
3. Name and/or Organization
3. Phone and/or FAX
Information to be exchanged includes records, reports, general collaboration, and
recommendations.

This information may be exchanged via phone, written documents, mail, fax, and email (no personally identifying information).

Information exchanged will be used solely for the purpose of evaluation and treatment planning for:
Child's Name
Birthdate

MonthDayYear
I understand that my records are protected and cannot be disclosed without my consent. I may revoke this authorization at any time.
I ________(insert name below), agree to the terms as listed and accept the electronic signature below
Parent/Guardian Signature

Clear
Date

DayMonthYear
SERVICE AGREEMENT 2024/25
NAME OF CLIENT(S):*
Cancellation Policy: If the need arises to miss a scheduled treatment session, we request notification as soon as possible. We allow one cancel in every six sessions without rescheduling a make-up session. Exceeding this limit will require rescheduling of missed sessions in order to avoid losing preferred session times. If there are frequent cancellations without rescheduling, we may need to make a change in the treatment frequency or current schedule. No shows may incur a fee.

Also, we work as a team, so thank you for working with substitute therapists when your usual therapist is not available!
****Initial HERE*
Caregiver Attendance: As a courtesy (and when appropriate), parents/caregivers may occasionally leave the premises during their child’s appointment(s). However, they must always be available by phone and must return 10 minutes prior to the end of the treatment session. When not in session, children will be supervised by a parent or caregiver at all times.
*****Initial HERE*
Illness/Emergencies: Clients must be without fever or vomiting at least 24 hours before attending appointments. Clients must also be well enough to participate in all aspects of treatment, without constant runny nose and/or coughing. We will call 911 if there is an emergency beyond our scope of reasonable first aid when parent/guardian is not on site.

Toileting: Staff will assist clients as needed with toileting if parents are not available. Therapists will not change diapers.

Risks of Treatment: There are inherent risks in participating in therapy. Client/Parent/Guardian assumes the RISK of treatment and RELEASES Advance Therapy and its staff from all claims of any nature, except those claims which may not be released pursuant to law.
I (Parent/Guardian) agree to the terms and conditions listed above.
I ________(insert name below), agree to the terms as listed and accept the electronic signature below*
SIGNATURE*

Clear
Date*

MonthDayYear
Date
FINANCIAL AGREEMENT
CLIENT(s):*
1. Medical Insurance: If requested, Advance Therapy will submit medical claims to your insurance company. Advance Therapy will help with verification of benefits under your insurance policy. In the event that a claim is not reimbursed by the insurance company, the parent/guardian is liable for payment.

All co-payments/co-insurance/deductibles are due either at the time of service, or billed on a monthly basis. Invoices are billed monthly through Great Lakes Medical Billing, but payments should be made directly to Advance Occupational Therapy, LLC (For OT and PT services) and to Advance Speech Therapy, LLC (For Speech services). The amount listed is the cash rate. Payments can be made to main office with a check. For your convenience, you may request an online payment link, however the amount will include a higher non-cash rate of 3.95%.
Overdue Balances: Balances are due no later than 30 days from invoice date. Overdue balances on any account will be charged to the credit card on file (see below) with a $25 late fee per account.
*****Initial HERE*
2. It is your responsibility to inform Advance Therapy of any and all changes in insurance and/or benefits/ reimbursement for services. This includes, but is not limited to group policy number and identification number. Failure to do so could result in client/parent/guardian responsibility for charges.

3. Prior to receiving services at Advance Therapy, it is imperative that each family check their insurance coverage for the services that we provide.
Your medical insurance may only cover a portion of the service rendered and it is difficult to predict the exact cost to you. Please contact your medical insurance provider and ask them the following questions:
1. Is Advance Therapy in-network with my specific plan?*

YesNo
2. What is my current deductible:*
...and how much has been met to date?*
After I have met my deductible, do I have co-insurance:*
...or a co-pay:*
3. Are there any visit count limitations for speech therapy/occupational therapy/physical therapy included in my plan?*

YesNo
If so, what is my visit limit:*
...and have any been used date?*
4. Are there any exclusions (habilitative?) on my policy for speech therapy/occupational therapy/physical therapy?*

YesNo
If so, please explain:*
• I understand that the information my insurance company provides me or Advance Therapy is not a guarantee of payment *****Initial HERE*
• I am responsible for understanding my insurance benefits *****Initial HERE:*
CREDIT CARD ON FILE:
- I authorize Advance Therapy to charge my credit card for any overdue balances.
- I will present my credit card at the first visit.
- I understand that there is a higher non-cash rate of 3.95% for using a credit card and a $25 late fee applied to my balance.
I ________(insert name below), agree to the terms as listed and accept the electronic signature below*
Client/Parent/Guardian signature*

Clear
Date*

MonthDayYear
Date
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.

We may use and disclose your medical records only for each of the following purposes; treatment, payment, and health care operations.

Treatment means providing, coordinating, or managing health care and related services by one or more health care providers.

Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.

Health care operations include the business aspects of running our practice such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example of this would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses and disclosers will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

YOUR RIGHTS: You have the following rights with respect to your protected health information, which you can exercise by providing a written request to the Privacy Officer:
- The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
- The right to reasonable requests to receive confidential communication of protected health information from us by alternative means or at alternative locations.
- The right to inspect and copy your protected health information.
- The right to amend you protected health information.
- The right to receive an accounting of disclosures of protected health information.
- The right to obtain a paper copy of this notice from us upon request.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with ADVANCE THERAPY or with the Secretary of the Department of Health and Human Services. To file a complaint with ADVANCE THERAPY, contact Jennifer Jensen at ADVANCE THERAPY 6776 Lake Drive #220, Lino Lakes, Minnesota 55014. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

ACKNOWLEDGEMENT OF RECEIPT OF THIS NOTICE
We request that you sign below acknowledging you were offered a copy of this notice. This acknowledgement will be filed with your records.
Acknowledgement of Receipt of Notice of Privacy Practices
I, _____________________, have read the Notice of Privacy Practices from ADVANCE THERAPY and was offered a copy.*
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

CLIENT INFORMATION:

NAME OF PHYSICIAN SUPPORTING THIS RECOMMENDATION (OR PRIMARY CARE PHYSICIAN):

PARENTS/LEGAL GUARDIANS:

INSURANCE:

PRIMARY INSURANCE COMPANY

SECONDARY INSURANCE COMPANY

AUTHORIZATIONS

INITIAL EVALUATION QUESTIONNAIRE

CONSENT TO RELEASE INFORMATION

SERVICE AGREEMENT 2024/25

I (Parent/Guardian) agree to the terms and conditions listed above.

FINANCIAL AGREEMENT

NOTICE OF PRIVACY PRACTICES