Autism & Support Services Child Intake Form

I hereby request and give my permission for the therapists of Easter Seals Southwest Florida to provide such medical examination and treatment as they deem best for the child. I voluntarily consent to therapy as determined to be necessary or beneficial in the professional judgment of my physician or therapist.  I acknowledge that no guarantees have been made to me as to the affect of such treatment on my child's  condition.

As client, parent, or legal guardian, I give my full consent to Easter Seals Southwest Florida’s clinical staff to provide medical examination and treatment for my child. I will submit a signed notification to the Easter Seals Southwest Florida Children’s Therapy Center of any change in the above information or permission.

I direct my insurer and third parties to pay directly to Easter Seals Southwest Florida any insurance benefits due for services on behalf of the patient. I hereby assign Easter Seals Southwest Florida all my rights to receive payments from my insurer and third parties for services rendered by Easter Seals Southwest Florida. As stated in the note on the front page of this packet, I understand that I am responsible for copayments and charges for non-covered services. I agree to accept full responsibility for all charges due upon receipt of statement.

Easter Seals Southwest Florida accepts cash, checks, and all major credit cards. Checks returned for insufficient funds (NSF) will be assessed a $25 returned check charge unless payment in cash is received within 48 hours following NSF notification. I understand I am responsible for any costs incurred in the collection of the patient’s account in case of default, including reasonable fees. Easter Seals Southwest Florida has a Financial Counselor available if needed to discuss any benefits or billing questions and/or to plan for your financial responsibilities. 

I agree that medical information regarding my child’s diagnosis and treatment may be released to the natural mother, natural father, stepmother/father, referring physician, and other physicians involved in the care of my child, and to the insurance company. Restrictions must be submitted in writing to our Privacy Officer.

give my permission to Easter Seals Southwest Florida to seek emergency medical treatment for my child.

In order to ensure efficient use of our therapists' schedules and to maintain a healthy environment, we have implemented the following policies:

1.  Arrive on time for your scheduled appointment.
2.  If you must cancel an appointment, call as far in advance as possible. Our phone number is (941) 355 - 7637 x482.
3.  No “No Shows” are permitted without a doctor’s note brought to the next visit.
4.  One cancellation is allowed allowed per month
5.  If you are 15 minutes late to an appointment, it is up to the therapist whether to see your child, and if your child is not seen, this appointment will count as a cancellation.
6.  If this policy is violated, your child will be discharged from therapy and placed on a waiting list. 

Please sign below to acknowledge that you have read and understand the above policy:

In exchange for consideration received, I hereby give Easter Seals Southwest Florida, Inc. the unrestricted right and permission to copyright, use, reuse, and publish photographic likenesses of

in all forms and media. I waive the right to inspect or approve the finished photograph or public relations copy of printed matter that may be used. I declare that I am at least 18 years of age and am the parent/legal guardian of the subject of this release, and give my consent. I understand that the photographs will only be used to promote the purposes of Easter Seals Southwest Florida, Inc.

I hereby release, discharge and agree to save harmless Easter Seals Southwest Florida, Inc., its successors or assigns, and all persons functioning under its permission or authority, from any liability by virtue of any blurring, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of the photographs or in any subsequent processing, as well as any publication thereof, including without limitation any claims for libel or invasion of privacy.

I have read and understand this photograph release prior to its execution and I fully understand the contents of this photograph release. This agreement shall be binding upon me and my heirs, legal representatives and assigns for a period of three years from the date below:

I hereby authorize the following persons, agencies, and/or programs to engage in verbal or written communication for my child/adult/family member. All pertinent records and information can be released between agencies as necessary. I am aware that this information will be Strictly Confidential and will be used in my child/adult/family member’s best interest in order to plan and provide the best programming to meet individual needs. I am aware that many agencies and programs will be working cooperatively to provide program opportunities and that effective interagency communication between them is essential. I realize that records may be reviewed by the funding agency in routine monitoring activities of the program.

I am also aware that I may deny consent for disclosure to any of the agencies or programs designated below.

This authorization includes release of information concerning HIV testing or treatment of AIDS, AIDS-related conditions, drug or alcohol abuse, drug-related conditions, alcoholism, and/or psychiatric or psychological conditions. Information will not be disclosed to any other party without prior written consent of the parent or legal guardian and will only be disclosed to personnel with a legitimate interest.

I give my consent for the agencies and programs listed to share information for the purpose of coordinating services for my child/family member. I understand my rights in regard to this consent.

I understand this program receives funding from Manatee County Government and that Manatee County representatives may request access to any or all Agency records related to Children's Therapy for the purpose of evaluating or monitoring the program delivery of services. I understand any records provided to Manatee County shall become public records and may be subject to applicable state or federal exemptions and may be copied and inspected by a third persons.

Authorization to release records is valid for the duration of treatment.

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Assignment of Benefits

I hereby assign to Easter Seals Southwest Florida any insurance or other third-party benefits available for services provided to me/my dependent. I understand that Easter Seals Southwest Florida has the right to refuse or accept assignment of such benefits. If these benefits are not assigned to Easter Seals Southwest Florida, I agree to forward to Easter Seals Southwest Florida all health insurance and other third-party payment that I receive for services rendered to me/my dependent immediately upon receipt.

Note: If you receive a check from your insurance company for therapy services given by Easter Seals, please bring it to our office as soon as possible.

Insurance Coverage Waiver

cannot be confirmed at this time. I wish to receive/I wish my dependent to receive services from Easter Seals Southwest Florida. If it is determined that I am not eligible for coverage, I understand that I will be responsible for payment for all services provided to me/my dependent.

Financial Responsibility Statement

I wish to receive/I wish my dependent to receive services from Easter Seals SW FL Children’s Therapy. I understand and agree that I am responsible for all eligible charges, including copayments, coinsurance and deductibles, as well as charges for services not covered by my insurance company or other benefit program for services provided to me/my dependent. I understand and agree to make payment in accordance with the payment policies established by Easter Seals Affiliate. 

ALTHOUGH YOUR CHILD MAY QUALIFY FOR THE STATE TO PAY FOR THERAPY SERVICES…

WE MUST BILL A FAMILY’S PRIMARY INSURANCE COMPANY FIRST BEFORE THE STATE COVERS THE COST. ONLY AFTER WE BILL YOUR INSURANCE COMPANIES AND GET A DENIAL WILL THE STATE REIMBURSE US. AS THE PROVIDER, WE SEND THESE DENIALS FROM THE INSURANCE COMPANY TO THE STATE AS PROOF THAT THE INSURANCE COMPANY WAS BILLED AND DID NOT PAY THE CLAIM(S). ONLY AFTER THIS PROCESS WILL THE STATE REIMBURSE THE COST.

PLEASE NOTE: IT IS THE PARENT/GUARDIANS RESPONSIBILITY TO MAINTAIN INSURANCE COVERAGE. ANY LAPSE IN COVERAGE WILL BE THE PARENT’S/GUARDIAN’S FINANCIAL RESPONSIBILITY. ANY UNPAID OUTSTANDING THERAPY BILL OVER 120 DAYS AFTER THE SERVICE WAS PROVIDED WILL BE FORWARDED TO A COLLECTIONS AGENCY. WE DO HAVE PAYMENT PLAN OPTIONS FOR FAMILIES. IF THE BILL REMAINS UNPAID AFTER 120 DAYS, WE RESERVE THE RIGHT TO DISCONTINUE THERAPY SERVICES DUE TO NON-PAYMENT FOR SERVICES RENDERED.

**IF YOU ARE RECEIVING SERVICES THROUGH EARLY STEPS, WE WILL BILL YOUR PRIMARY INSURANCE FIRST AND THEN WE WILL BILL EARLY STEPS FOR THE REMAINDER OF WHAT MAY NOT BE COVERED.**

I understand that this form, or copy thereof, is valid for twelve (12) months from the date of this agreement.

It is our goal to make your child’s therapy and developmental journey an enjoyable experience. We strongly believe that parents are experts when it comes to their children and therapists are specialists and facilitators. We are committed to empowering and supporting parents with the necessary information and skills to assist with their child’s development.

Below, please find the roles and expectations of parent and clinician.

Parent Commitment:

1.  Cancel appointment 24 hours before the scheduled appointment time if unable to participate.

2.  Arrive to scheduled sessions on time and attend on a consistent schedule.

3.  Cancel appointment if child or other family member has a fever of 101 degrees or higher or is exhibiting other symptoms of illness.  

4.  Be prepared to participate and learn with child during the appointment

5.  Be prepared to participate with a home program.

6.  Take responsibility for other children brought to the center and follow the safety rules.

7.  Refrain from using cell phones during child’s appointment.

8.  Share information about child with clinician that may benefit the child’s progress and/or participation.

9.  Communicate expectations openly with clinician.

10. Please bring appropriate baby items to center. i.e.: diapers, wipes, etc.

Therapist or Early Interventionist Commitment:

11.  Cancel appointment within 24 hours if unable to participate.

12.  Cancel appointment if I have a fever of 101 degrees or higher, or exhibiting other symptoms of illness.

13.  Be prepared to develop and teach parent strategies to meet the goals identified on child’s Plan of Care.

14.  Provide information about resources and new techniques that may benefit child.

15.  Begin and end sessions on time. 

16.  Involve parent in therapy process.

17.  Provide ongoing communication about child’s participation, progress, or challenges. 

18.  Provide home program to the parent/caregiver.
 

Our goal is to provide the child and family with a comfortable and supportive environment. In the event that a parent or therapist has a concern that has not been effectively resolved, the Clinical Director may be contacted at 355-7637 x421.  Parents will also receive frequent surveys that will help us monitor and improve our services.

Please note that two or more “no shows” (no call to cancel appointment) in one month will result in the child being placed on hold until parent can resume a consistent therapy schedule.

Easter Seals Southwest Florida is committed to protecting medical information all and is required by law to:

• Make sure all medical information is protected;
• Give you this Notice describing our legal duties and privacy practices with respect to medical information; and
• Follow the terms of the Notice that is currently in effect.

I consent to the use and/or disclosure of my dependent’s protected health information by Easter Seals Southwest Florida for the purpose of diagnosing or providing treatment, obtaining payment for health care bills, or to conduct health care operations.  I understand that diagnosis or treatment services provided to my dependent by Easter Seals Southwest Florida clinical staff may be conditioned by my consent as evidenced by my signature on this document. 

I understand I have the right to request a restriction as to how my dependent’s protected health information is used or disclosed to carry out treatment, payment, or healthcare operations of the practice.  Easter Seals Southwest Florida is not required to agree to the restrictions that I may request.  However, if Easter Seals Southwest Florida agrees to a restriction that I request, the restriction is binding, except where medical information disclosure is required by Federal or State law. 

I have the right to revoke this consent, in writing, at any time. Easter Seals Southwest Florida requires a dated and signed request along with notification of the duration of the request. 

“Protected Health Information” (PHI) means health information, including demographic information, collected from me and created or received by physicians, another health care provider, a health plan, my employer or a health care clearinghouse.  This PHI related to past, present, or future physical or mental health or condition and identifies my dependent, or there is a reasonable basis to believe the information may identify me/my dependent.

The Notice of Privacy Practices describes the types of uses and disclosures of protected health information that will occur in treatment, payment of bills, or in the performance of health care operations of Easter Seals Southwest Florida.

I acknowledge I have received a copy of the 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.

Under federal law, patient health information is protected and confidential.  Patient health information includes information about symptoms, test results, diagnosis, treatment, related medical data, payment, billing, and insurance information.

 PLEASE REVIEW IT CAREFULLY
 

Allowed Uses and Disclosures of Medical Information:

• Treatment – such as ordering diagnostic tests, other health care providers (ex: PCP,) Pharmacy, etc.
• Payment – such as submitting billing information to your insurance company, disclosures to consumer reporting agencies (limited to specified identifying information about the individual, his or her payment history, and identifying information about the covered entity.)
• Health Care Operations – such as quality assurance review, coordination of care, and eligibility verification.
• Public Health Activities – such as child abuse or neglect.

You have a right to:

• Request restriction on uses and disclosures about treatment, payment or healthcare operations, however, we are not required to agree to any restriction. Restrictions must be submitted in writing to our Privacy Office or designee indicating (1) what information you want restricted; (2) whether you want to limit our use; (3) to whom you want the limits to apply.
• Receive confidential communications from us, upon written request.
• Inspect and request copies of your medical information.
• Request to amend incorrect or incomplete medical information.
• Receive an accounting of any disclosures made, upon written request.
• Receive a paper copy of the notice upon request or review our entire policy.

We are required to:

• Maintain the privacy of all clients’ medical information.
• Provide you with this notice and obtain written acknowledgement.
• Abide by the terms of this notice.
• Provide written notice of any change to this notice.
• Report information to federal, state, and local agencies when it is required by law.

Complaints:

You may complain to us or to the Health & Human Services secretary if you believe that your privacy has been violated. If you wish to file a complaint with us, please provide the office manager with written notice of how you believe we violated your privacy. All notices received will be investigated and reviewed by the Privacy Officer or designee. Easter Seals Southwest Florida encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against for filing a complaint.

Authorizations:

Upon your written authorization, we may disclose your medical information to a requesting entity.  You may revoke any authorization you make at any time, except to the extent that it was already relied on.

Patient Contact:

We need to contact you to provide test results, appointment reminders, treatment information, or for patient satisfaction surveys. Our appointment reminders are done by telephone. If you wish to request alternative or confidential communication, please contact our Clinical Manager.

To obtain information, contact: Privacy Officer or designee at:

Easter Seals Southwest Florida
350 Braden Avenue
Sarasota, FL  34243