Date of Birth
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Patient First Name & Last Name
Patient Demographic Information
Spouse Phone Number
Spouse Email Address
Are you a Veteran?
Responsible Party Relationship to Patient
Name of Responsible Party (if not patient)
Responsible Party Phone
Name of Emergency Contact
Relationship to Patient
Emergency Contact Phone
Primary Care Physician
Primary Care Physician Phone
Please upload a copy of a photo ID, front of insurance card and back of insurance card
Acknowledgement Receipt of Notice of Privacy Practices
A print copy will be supplied when requested.
Your Information. Your Rights. Our Responsibilities.
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. Your Rights You have the right to: • Get a copy of your paper or electronic medical record • Correct your paper or electronic medical record • Request confidential communication • Ask us to limit the information we share • Get a list of those with whom we’ve shared your information • Get a copy of this privacy notice • Choose someone to act for you • File a complaint if you believe your privacy rights have been violated Your Choices You have some choices in the way that we use and share information as we: • Tell family and friends about your condition • Provide disaster relief • Include you in a hospital directory • Provide mental health care • Market our services and sell your information • Raise funds Our Uses and Disclosures We may use and share your information as we: • Treat you • Run our organization • Bill for your services • Help with public health and safety issues • Do research • Comply with the law • Respond to organ and tissue donation requests • Work with a medical examiner or funeral director • Address workers’ compensation, law enforcement, and other government requests • Respond to lawsuits and legal actions Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get an electronic or paper copy of your medical record • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. • We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. • We will say “yes” to all reasonable requests. Ask us to limit what we use or share • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. • We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated • You can complain if you feel we have violated your rights by contacting us using the information on page 1. • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. • We will not retaliate against you for filing a complaint. Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: • Share information with your family, close friends, or others involved in your care • Share information in a disaster relief situation • Include your information in a hospital directory If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission: • Marketing purposes • Sale of your information • Most sharing of psychotherapy notes In the case of fundraising: • We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you We can use your health information and share it with other professionals who are treating you. Run our organization We can use and share your health information to run our practice, improve your care, and contact you when necessary. Bill for your services We can use and share your health information to bill and get payment from health plans or other entities. How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues We can share health information about you for certain situations such as: • Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety Do research We can use or share your information for health research. Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Respond to organ and tissue donation requests We can share health information about you with organ procurement organizations. Work with a medical examiner or funeral director We can share health information with a coroner, medical examiner, or funeral director when an individual dies. Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you: • For workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective services Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities • We are required by law to maintain the privacy and security of your protected health information. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. Effective Date of this Notice: 01/01/2015 Filing a HIPAA Complaint If you believe your privacy rights have been violated by JSHC or one of its employees, you may file a complaint with the Secretary of the Department of Health and Human Services at the addresses below. You will not be retaliated against for filing a complaint. Department of Health and Human Services 200 Independence Ave. SW Washington, D.C. 20201 (800) 368-1019
I have received a copy of Jacksonville Speech & Hearing Center's Notice of Privacy Practices effective 01/01/2015. Enter name below to acknowledge by electronic signature.
Relationship to Patient
I agree to accept financial responsibility for all services rendered to me (or my child) by Jacksonville Speech & Hearing Center that are not covered by my health insurance plan. Payment for services/supplies not covered by insurance are due at the time those services/supplies are provided. If services are provided by my insurance, I understand that I will not be financially responsible for those services.
Enter initals below to acknowledge financial responsibility
I understand that Jacksonville Speech & Hearing Center will periodically take photographs to promote their services to the community. These photos may include me and/or my minor child. I authorize Jacksonville Speech & Hearing Center to use the photographs for their intended purposes.
Enter initials below to acknowledge Promotional Considerations.
Release of Medical Information
I authorize Jacksonville Speech & Hearing Center to release medical information that may be necessary for medical evaluation, treatment, consultation or the processing of insurance benefits. I understand that this release will remain in force for as long as I am an active patient and for 5 consecutive years thereafter unless revoked in writing. Written revocation can be submitted to the address provided at the top of this form. I understand that revocation request will exclude any information shared prior to receipt by Jacksonville Speech & Hearing Center staff.
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Patient's Speech & Language Case History
Has speech or language been evaluated before?
If evaluated before, when and where?
What concerns are we seeing the patient for today?
Speech (the way sounds are pronounced)
Receptive Language (following directions, understanding)
Expressive Language (vocabulary, using sentences)
Swallowing (or eating)
When did you first notice the problem(s)
There is a diagnosed family history of:
There is a diagnosed family history of:
List family members living with the patient.
Are any languages aside from English spoken in the home?
None - Only English is spoken
What is the primary language spoken in the home?
Health & Development History
Which of these apply to the patient birth & hospital stay?
Defect of ear/nose/throat/mouth
Low Birth Weight
Any difficulties with feeding (sucking/swallowing)?
Was there use of a feed tube (NG)?
Are there any other birth defects or difficulties we should know about?
Does a patient have a history of the following conditions?
Attention deficit disorder
Traumatic brain injury
Hearing loss/hearing aids
If "Yes" or "Unknown" selected to any of the options above, please explain.
Please list all current medications.
Please list any major surgeries.
Please list any serious illness, accident or injury.
Have all of the following developmental stages been met as expected?
Other developmental concerns
If "No" or "Unknown" selected to any of the options above, please explain.
Difficulty following directions
Short attention span
Easily managed at home
Nervous or sensitive
Confused in noisy places
Profits from discipline
Sesitive to loud noises
Prefers to play alone
Plays well with others
At what age did the patient say their first word?
Approximately how many words can the patient currently say now?
Does the patient have the ability to combine two or more words together (such as "want drink" or "mommy car")?
Does the patient...
repeat sounds, words or phrases over & over?
understand what you're saying?
retrieve/point to comon objects upon request?
follow simple directions?
respond correctly to yes/no questions?
respond correctly to who/what/where/when/why questions?
Does the patient currently communicate using...
follow simple directions?
2-4 word sentences?
sentences longer than 4 words?
List school or occupation.
Is there anything additional information you would like your therapist to know?
Are there any questions you have for your therapist?
By electronically signing below I confirm that the information provided within these forms is true and accurate.
Enter FULL NAME below for electronic signature
Enter today's date
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Please upload a picture of your insurance cards (front/back) and photo ID.
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