Welcome to On Target Pediatric Therapy, LLC. We look forward to working with you and your child. Please fill out the following pages to the best of your ability. This paperwork will remain confidential. If you feel uncomfortable with a question below or are unsure how to answer it, please let us know prior to your initial treatment session.Please bring the following items to your child’s first session: pediatrician's prescription for therapy, child’s insurance card and your IDSome things to keep in mind for your first session/evaluation:
Thank you so much for your understanding. We look forward to working with you and your child.
Please be aware that e-mail is not a completely secure method of communication.I acknowledge that staff members have my permission to correspond via the above email address(es). Name: First Name Last Name Relationship to Child: Signature: Signature Date: Date
Referring Pediatrician Name of Physician's practice Phone Number Please be aware that by signing below you are expressing your understanding that we can send any records to the physician on file.
What age did your child reach the following milestones:Rolling Sitting Walking Talking
Communication between our therapists and child’s teachers, other therapists and other professionals involved in your child’s care is often beneficial. If you sign below, you are allowing our therapists to communicate with child’s teachers, psychologists, case workers, other physicians or other members of your child’s team. Please add any comments below if you have any requests. Signature Signature Date Date Additional Comments:
Health Insurance Company Member ID Phone number Phone Number Name of Primary Insured First Name Last NameSocial security number of Primary Insured Insured's date of birth Date Insured's address (If different from above) Street Address Address Line 2 City State Zip Insured's Phone number Area Code Phone Number Employer Benefit's Phone Number (on back of card) Phone Number Do you have secondary insurance? If yes, please provide information below:
I consent to necessary examination procedures and/ or treatment for my child by a member of the On Target Pediatric Therapy Team. I authorize the release of any medical or other information necessary to process claims. I also request payment of benefits to On Target Pediatric Therapy LLC for services provided and claimed.Signature Signature* Date Date* I have been offered a copy of On Target Pediatric Therapy's Notice of Privacy Practices, have reviewed it and agree to it (see following page).Name First Name* Last Name* Signature Signature* Date Date*
The notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPPA). It describes how we may use or disclose your child's protected health information, with whom that information may be shared, and the safeguards we have in place to protect it. This notice also describes your rights to access and or refuse the release of specific information outside of the system except when the release is required or authorized by law or regulation.Acknowledgment of Receipt of this NoticeYou will be asked to provide a signed acknowledgment of receipt of this notice. The intent is to make you aware of the possible uses anddisclosures of your child's protected health information and your privacy rights. The delivery of your child's health care services will in no way beconditioned upon your signed acknowledgment.Who will follow this NoticeThis notice applies to all therapy services provided by On Target Pediatric Therapy LLC. It also applies to office and billing personnel.Our responsibility regarding Protected Health InformationYour child's 'protected health information' is individually identifiable health information. This includes demographics such as age, address, emailaddress, and relates to your child's past present or future physical or mental health or condition and related health care services. We arerequired by law to do the following:● Make sure that your child's protected health information is kept private● Give you this notice of our legal dues and privacy practices related to the use and disclosure of your child's protected healthinformation● Follow the terms of the notice currently in effect● Communicate any changes in the notice to you.We reserve the right to change this notice. Its effective date is at the top of the first page and the boom of the last page. We reserve the rightto make the revised or changed notice effective for health information we already have about your child as well as any information received inthe future. You may obtain a Notice of Privacy Practices by calling the phone number at the top of this notice.Our SystemOn Target Pediatric Therapy LLC works with several agencies and referral sources. Your child's health information will be shared inthe following manner:1. Treatment - We will use or disclose your child's protected health information to provide, coordinate or manage your child'shealth care and any related services. This includes disclosure to your physician or other health care providers who willbecome involved in your child's care2. Within our office for administrative activities, quality assessment, oversight and peer review.3. With our billing personnel and as necessary to obtain payment for your health care services.4. With your insurance company or other payers as required for payment.5. With the referring agency and case manager, if applicable.6. With any provider, school or agency with your written consent. You may request written or verbal information sharing inwriting. Your request should include a specified period of time for information sharing.Required by LawWe may use or disclose your child's protected health information if law or regulation requires the use or disclosure. We will notify theappropriate government authority if we believe the patient has been a victim of abuse, neglect or domestic violence.Health OversightWe may disclose protected health information to a health oversight agency for activities authorized by law such as audits,investigations and inspections. These health oversight agencies may include government agencies that oversee the healthcaresystem, government benefit programs, other government regulatory programs and civil rights laws.Legal ProceedingsWe may disclose protected health information during any judicial or administrative proceeding, in response to a court order oradministrative tribunal (if such a disclosure is expressly authorized), and in certain conditions in response to a subpoena, discoveryrequest or other lawful purposes.Parental AccessWe may disclose your child's protected health information to parents, guardians and person's acting in similar legal status.Uses and Disclosure of Protect Health Information Requiring your PermissionIn some circumstances you have the opportunity to agree or object to the use or disclosure of all or part of your child's protectedhealth information. Since this service may be provided in a natural environment, others present during a session such as familymembers, friends or day care providers may hear health information regarding your child. Please notify your therapist if you do notwant your child's protected health information to be discussed.Your rights regarding your Child's Health InformationYou may exercise the following rights by submitting a written request to the On Target Pediatric Therapy office.1. You may inspect and obtain a copy of your child's protected health information that is kept as a part of medical and billingrecords.2. You may ask us not to use or disclose any part of your child's health information for treatment, payment or health careoperations. Your request must be made in writing. This request will be honored if we mutually agree that the restriction willnot harm your child.3. You may request that we communicate with you using alternate means. We will not ask the reason for your request andwill accommodate reasonable requests when possible.4. If you believe that the information we have about your child is incorrect or incomplete you may request an amendment toyour child's protected health information as long as we are responsible for and maintain this information. While we willaccept your requests for amendment, we are not required to agree to the amendment.5. You may requests that we provide you with an accounting of the disclosures we have made of your child's protectedhealth information. This right applies to disclosures made for purposes other than treatment, payment, or health careoperations as described in this Notice of Privacy Practices. This disclosure must have been made after September 1st,2015, and no more than 6 years from the date of the request. This right excludes disclosures made to you or authorizedby you to family members or friends involved in your child's care, or for notification. The right to receive this information issubject to additional exceptions, restrictions and limitations as described earlier in this noticeFederal Privacy LawsThis notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act(HIPAA). There are several other privacy laws that also apply including the Freedom of Information Act and the Privacy Act. Theselaws have been taken into consideration in developing policies and this notice of how we will use and disclose your child's protectedinformation.ComplaintsIf you believe these privacy rights have been violated, you may file a written complaint with the Department of Health and humanServices. No retaliation will occur against you for filing a complaint.This notice is effective in its entirety as of November 1st 2015.
Children requiring therapy benefit greatly from an alliance between the parents and therapist. Most therapy sessions include demonstrations of techniques for parents so they can follow through with observed and recommended activities. Your child requires your assistance in order to progress. If your regular child care provider will be accompanying the child to his/her therapy session, you may provide permission for that provider to be present during therapy sessions.I give permission to attend therapy sessions with my child. The therapists at On Target Pediatric Therapy have my permission to provide any relevant medical information necessary to provide service and instruct him/her regarding home exercise programsSignature Signature Date Date
At On Target Pediatric Therapy LLC we value your time. Should a situation arise where we cannot keep to your scheduled appointment time, we will do our best to inform you of the scheduling change in a timely and efficient manner. Likewise, we ask that you honor the time and schedule of other clients and our therapists by confirming all cancellations at least 24 hours before your scheduled appointment. Failing to do so will result in a non refundable $50 cancellation fee. If you arrive for your session more than 10 minutes late, you may be charged a late fee of $50. Additionally, the session may need to be rescheduled based upon the discretion of On Target Pediatric Therapy. If you have failed to show up for your scheduled session and/or cancelled less than 24 hours in advance three times, we reserve the right to cancel all future appointments. Additionally if you cancel with more than 24 hours notice or by text reminder for 25% or more of your sessions over a two month period, or 50% of sessions over a one month period we reserve the right to cancel all future appointments as therapy slots are in high demand and we are unable to reserve the spot for families who are not consistently attending appointments. If your child is taken off the schedule due to multiple no shows or cancellations, in order to be allowed back on the schedule (at the discretion of staff) we charge a $50 reinstatement fee. I have read and agree to On Target Pediatric Therapy's cancellation policy.Guardian Name First Name* Last Name* Date Date* Signature Signature*
We ask your cooperation by coming to the office prepared to pay for services rendered. While we do our best to contact your insurance provider to acquire an understanding of your benefits before treatment is rendered, it is your responsibility to confirm these benefits with your insurance. Please discuss any questions regarding applicable copayments, co-insurances, or deductibles with office staff at least 1 business day prior to your appointment. If you switch insurance, you are required to let the office know no less than 2 weeks prior to the change. I hereby authorize the release of any medical information necessary to process insurance claims. I hereby authorize payment of, and assign my rights to, any health insurance or medical plan benefits directly to On Target Pediatric Therapy, LLC (OTPT) for any and all therapy services that have been or will be rendered or provided. I Understand that I am financially responsible for all charges whether or not paid by my insurance and that copayments and deductibles are due at time of service unless I am told otherwise by office staff.Date Date* Name First Name* Last Name* Signature Signature*
In agreeing to receive care provided by On Target Pediatric Therapy LLC and to use the facilities provided therefore located at 1270 McConnell Dr, Suite B Decatur GA 30033, I agree as follows: I fully understand and acknowledge that (a) the activities in which my child will engage as part of the treatment provided by On Target Pediatric Therapy and the therapy activities and equipment he/she may use as a part of that treatment have inherent risks, dangers, and hazards and such exists in use of any equipment and participation in these activities; (b) participation in such activities and/or use of such equipment may result in injury or illness including, but not limited to bodily injury, disease, strains, fractures, partial and/or total paralysis, death or other ailments that, could cause serious disability; (c) these risks and dangers may be caused by the negligence of the representatives or employees of On Target Pediatric Therapy LLC, the negligence of the participants, the negligence of others, accidents, breaches of contract, or other causes. By my child’s participation in these activities and for use of equipment, I hereby assume all risks and dangers and all responsibility for any losses and/or damages whether caused in whole or in part by the negligence or the conduct of the representatives or employees of On Target Pediatric Therapy LLC, or by any other person. I, on behalf of my child, hereby voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify On Target Pediatric Therapy LLC and their representatives, employees, and assigns from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of the use of any equipment or participation in these activities. I specifically understand that I am releasing, discharging, and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the representatives or employees of On Target Pediatric Therapy LLC. I HAVE READ THE ABOVE WAIVER AND RELEASE AND BY SIGNING IT AGREE. IT IS MY INTENTION TO EXEMPT AND RELIEVE ON TARGET PEDIATRIC THERAPY LLC FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE OR ANY OTHER CAUSE. Guardian name First Name* Last Name* Guardian Date of Birth Date* Signature Signature* Date Date*