Auburntherapy_CLIENT

CLIENT REGISTRATION
Client Information
Name

First NameMiddle NameLast Name
Address
City
State
Zip
Date of Birth

MonthDayYear
Date
Social Security Number
MaleFemale
Phone (Home)
Phone (Cell)
Phone (Cell)
Email Address
example@example.com
Primary Concern
African AmericanAsian/Pacific IslanderCaucasianHispanicNative AmericanOther
Preferred Method of Contact
Languages Spoken
Primary Language Spoken in the Home
Primary Care Physician
Referred By
YesNo
If yes, please provide the best number to receive text messages
Please enter a valid phone number.
Emergency Contacts
Name
Relationship
Phone
Name
Relationship
Phone
Parent/Guardian Information (If Client is a Minor)
Name

First NameMiddle NameLast Name
Yes
Address
City
State
Zip
Date of Birth

MonthDayYear
Date
Social Security Number
MaleFemale
Phone (Home)
Phone (Cell)
Phone (Cell)
Email Address
example@example.com
Preferred Method of Contact
MarriedSingleDivorcedAdoptiveFoster
Relationship to Client
Insurance
Primary Insurance Company Name
Policy ID Number
Group Number
Yes
Policy Holder Information

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
Phone
Secondary Insurance Company Name
Policy ID Number
Group Number
Yes
Policy Holder Information

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
Phone
I give permission for Auburn TLC to discuss by phone/in person my evaluation, treatment and/or billing status with the following people:
1. Name, Relation and phone number
2. Name, Relation and phone number
Assignment and Release
I, the undersigned, certify that I, or my dependent have/has insurance coverage as indicated above and assign directly to Auburn Therapy and Learning Center all insurance benefits. A quote of benefits and/or authorization does not guarantee payment or verify eligibility. Payment of benefits is subject to all terms, conditions, limitations and exclusions of the member’s contract at time of service.. Your health insurance will only pay for services that it determines to be “reasonable and necessary.” If your health insurance company determines that a particular service is not reasonable and necessary, or that a particular service is not covered under the plan, your insurer will deny payment for that service. I understand that if my health insurance denies payment, I agree to be personally and fully responsible for payment. AGREEMENT TO PAY: I, the undersigned, accept the fee charged as a legal and lawful debt and agree to pay said fee, including any/all collection agency fees, (33.33%), attorney fees and/or court costs, if such be necessary.

EXPRESS PRIOR CONSENT TO CONTACT CONSUMER BY CELL PHONE: You agree, in order for us to service your account or to collect monies you may owe, Auburn Therapy and Learning Center and/or our agents may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We and/or our agents may also contact you by sending text messages or emails, using any email address you provide to use. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing device, as applicable. I/We have read this disclosure and agree that, Auburn Therapy and Learning Center, its employees, and/or agents, .may contact me/us by any permissible method described above. You agree that any permissible contact may include the use of pre-recorded and/or artificial voice messages and/or the use of an automatic telephone dialing system.

I understand that I have the right to review the Notice of Privacy Practices before signing this consent. Auburn TLC reserves the right to revise its Notice of Privacy Practices at any time. A request for a copy of the Notice of Privacy Practices may be sent in writing to Auburn TLC, 2000 Samglenn Drive, Suite 100, Auburn, AL 36830

I may revoke or edit this authorization in writing except to the extent disclosures of PHI have already been made based on my prior consent.
Signature of Client or Parent/Guardian

Clear
Date

MonthDayYear
Date
CREDIT CARD AUTHORIZATION
By signing below, you authorize Auburn Therapy and Learning Center to charge your credit card for services rendered. You have the right to request a paper copy of this authorization.

I authorize Auburn Therapy and Learning Center to charge my credit card for therapy services provided. I also agree that my credit card may be charged $40 per session that is not canceled at least 12 hours prior to the scheduled appointment time and $80 per session for any session that is marked as a no show. I understand that this authorization will remain in effect until I cancel it in writing. I agree to notify Auburn Therapy and Learning Center in writing of any changes to my credit card information or of my intent to terminate this authorization.

I certify that I am an authorized use of this credit card and agree not to dispute these authorized charges with my bank or credit card company, provided the transactions align with the terms outlined in this authorization. I acknowledge that credit card transactions may be linked to Protected Health Information (PHI).
Guardian Signature

Clear
Date

MonthDayYear
Date
AUBURN TLC ATTENDANCE POLICY
PLEASE READ CAREFULLY!

We reserve your appointment time just for you. We do not double-book our clients so that we may provide optimum treatment services for all clientele. Advanced notification allows us to potentially place another client during your cancelled appointment time to receive necessary treatment. We kindly ask for at least 24 hours’ notice (e.g., cancel by 8:30am Tuesday for an 8:30am Wednesday appt.). Please note that your treatment plan has been created and established by your therapist to help gain skills and daily living abilities. Missing appointments can hinder that process and may extend the need for treatment services. To ensure quality care and efficient scheduling, Auburn Therapy and Learning Center enforces the following Policy.

• NO SHOW: Missing an appointment without prior notice

o 1st occurrence: You will get a reminder call and will be asked to reschedule

o 2nd occurrence within 6 weeks: You will be removed from the schedule, but you may call weekly to see if there is an opening.

• LATE CANCELLATION: Canceling with less than 12 hours’ notice.

o 1st occurrence: You will get a reminder call and will be asked to reschedule

o 2nd occurrence within 6 weeks: Placed on the waiting list until availability suits your schedule, but you may call weekly to see if there is an opening.

Please notify us as soon as possible and communicate any scheduling concerns promptly.

By signing below, you acknowledge and agree to this policy.
Signature of Client or Parent/Guardian

Clear
Date

MonthDayYear
Date
AUTHORIZATION AND PERMISSION TO DISCUSS
Client Name
Date

MonthDayYear
Date
PLEASE INITIAL EACH STATEMENT
PERMISSION TO EVALUATE: I hereby give permission to Auburn Therapy and Learning Center (Auburn TLC) to conduct an evaluation of the speech, language and/or fine motor abilities of the above named individual.
PERMISSION TO TREAT: If the results of the evaluation(s) procedures indicate the need for therapy, I give permission to Auburn TLC to provide treatment for the above named individual.
PERMISSION TO DISCUSS AND CONTACT: I give permission for any information regarding evaluations or treatment to be discussed by phone, mail, or email with the below listed individuals:
Name
Email
example@example.com
Phone
Name
Email
example@example.com
Phone
I may revoke or edit this information in writing, except to the extent the disclosures of PHI have already been made based on my prior consent.
LIABILITY AGREEMENT: I release Auburn TLC of liability of any nature arising from my/the client's participation in procedures and activities at Auburn TLC.
AUTHORIZATION FOR RELEASE OF CLINICAL INFORMATION: I consent to the release of confidential material, related to evaluation and treatment procedures, to qualified professional personnel in furtherance of clinical services on behalf of the above-named person, as deemed necessary by personnel of Auburn TLC.
I have received the Notice of Privacy Practices information (HIPAA Policy) and I have been informed of my rights regarding services provided by Auburn TLC.
Client/Guardian Signature

Clear
Printed Name
Health Information Portability and Accountability Act (HIPAA) Notice of Privacy Practices Form
This is a summary of the Notice of Privacy Practices for Auburn Therapy and Learning Center (Auburn TLC This document describes how we may use and disclose your protected health information (PHI), and how you may access this information. This summary applies to the clinical programs of Auburn TLC including (but not limited to) speech-language pathology and occupation therapy clients. These policies are effective as of October 31, 2017. Please review this document carefully.

The Privacy Rule requires that we protect the privacy of health information that identifies patients, or when there is reasonable basis to believe, the information can be used to identify a patient. This Notice describes your rights as a patient and our obligations regarding the use and disclosure of PHI.

Uses and Disclosures for Treatment, Payment and Health Care Operations Auburn TLC may use or disclose your personal health information (PHI) for treatment, payment and health care operations without your consent. To clarify this information, please see definitions for some commonly used terms below:

"PHI" refers to protected health information in your healthcare record that could identify you.

"Treatment, payment and healthcare operations"

Treatment is when Auburn TLC provides, coordinates or manages your healthcare and/or other services related to your healthcare.
Example: We may consult and share PHI with another health care and/or educational provider in connection with your diagnosis and treatment, or if you are referred to another health care provider.

Payment is when Auburn TLC receives reimbursement for your healthcare.
Example: We may use or disclose PHI with another party to obtain reimbursement for your care, or to obtain information about eligibility or coverage.

Health Care Operations are activities that relate to the performance and operation of Auburn TLC. Example: We may mail reminders, or leave phone messages asking you to return our call, or to remind you of an appointment.
Example: We may provide PHI to student clinicians of local universities as a part of their training and educational program.
Example: We may disclose PHI if you pose a danger to yourself and/or others.

"Use" applies to activities that occur within Auburn TLC such as sharing, employing, applying, utilizing, examining, and analyzing information that may identify you.

"Disclosure" refers to activities that occur outside Auburn TLC. These are things such as releasing, transferring or providing access to information to other parties about you.

We may disclose your PHI to you.

We may use or disclose your PHI in order to treat you, obtain payment for services rendered, or operate Auburn TLC.

Other uses and disclosures may be made without your consent if the law requires us to release PHI.

Uses and Disclosures Requiring Authorization
When Auburn TLC is asked to disclose information for purposes other than treatment, payment or health care operations as they relate to our facility, Auburn TLC will obtain written authorization from you before releasing PHI. This authorization will also be required prior to releasing your Clinical Record. To clarify please see the definition of authorization below:

"Authorization" is written permission given by the patient or legal guardian above and beyond the general consent already allowed.
Patient Rights

You may request a restriction regarding uses and disclosures of your PHI however, Auburn TLC is not required to agree to your request.

You may request a restriction of disclosure to a health plan where all services were paid out of pocket (by you) in full

You may request that any communication regarding your PHI remain confidential, or that Auburn TLC contact you in a specific way (home phone, cell phone, email You may request to inspect your PHI.

You may request a copy of your PHI.

You may ask that your PHI be amended. You may ask for a copy of Auburn TLC Notice of Privacy Practices in an alternative format (paper, electronic

You may revoke your authorization in writing except to the extent that Auburn TLC has already acted upon it.

You have the right to receive a record of accounting of disclosures of your PHI.

Our Responsibilities

We are required by law to maintain the security and privacy of all PHI.

We are required to provide all patients with our Notice of Privacy Practices.

Though Auburn TLC reserves the right to change the policies in this notice, we must alert all patients of changes made in writing, or adhere to the terms currently in effect.

We will notify individuals affected by suspected security breach regarding PHI.

Questions or Concerns

Please address any questions or concerns you may have, or request a copy of Auburn TLC Notice of Privacy Policy, by mail to the address below:

Auburn Therapy and Learning Center
2408 E. University Drive, Suite 109
Auburn, AL 36830

If you feel your rights have been violated you may file a complaint without fear of retaliation:

You may file a complaint by contacting us in writing at Auburn TLC, 2408 E. University Drive, Suite 109, Auburn, AL 36830

You can file a complaint in writing with the U.S. Department of Health and Human Services Office for Civil Rights, 200 Independence Avenue SW, Washington, DC 22201, or by visiting www.hhs.gov/ocr/privacy/hipaa/complaints/
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CLIENT REGISTRATION

Client Information

Emergency Contacts

Parent/Guardian Information (If Client is a Minor)

Insurance

Assignment and Release

CREDIT CARD AUTHORIZATION

AUBURN TLC ATTENDANCE POLICY

AUTHORIZATION AND PERMISSION TO DISCUSS

Health Information Portability and Accountability Act (HIPAA) Notice of Privacy Practices Form