Guardian Name: First Name*   Last Name*   

Guardian date of birth   Date*   

Relationship to Child:    *       

Guardian Signature:   Signature*   Date:   Date*   

PLEASE NOTE:
MOST INSURANCES will only cover ONE EVALUATION, either EVERY 6 MONTHS or ONE EVALUATION EVERY CALENDAR YEAR (this does not apply to Music Therapy).

Therefore, if you do not inform us of prior, recent evaluations, OR if your child's insurance (including ALL Medicaid insurances) does not cover the initial evaluation at our clinic due to a recent evaluation, we will bill you the full, $200 at the time of service. If we discover that insurance will cover part or all of the evaluation cost, then we will reimburse the patient accordingly.

By signing below, I understand the policy stated above and agree to accept financial responsibility as described.


Signature*   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.      

Guardian Signature   Signature*   Date   Date*  

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*      

Health Insurance Company (If Private Pay, write "Private")   *   
Member ID     Type a label   
Phone number      Phone Number   
Name of Primary Insured   First Name   Last Name
Social security number of Primary Insured   Number   
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*  

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 Notice

You will be asked to provide a signed acknowledgment of receipt of this notice. The intent is to make you aware of the possible uses and disclosures of your child's protected health information and your privacy rights. The delivery of your child's health care services will in no way be conditioned upon your signed acknowledgment.

Who will follow this Notice

This 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 Information

Your child's 'protected health information' is individually identifiable health information. This includes demographics such as age, address, email address, and relates to your child's past present or future physical or mental health or condition and related health care services. We are required 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 health

information

● 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 right to make the revised or changed notice effective for health information we already have about your child as well as any information received in the future. You may obtain a Notice of Privacy Practices by calling the phone number at the top of this notice.

Our System

On Target Pediatric Therapy LLC works with several agencies and referral sources. Your child's health information will be shared in the following manner:

1. Treatment - We will use or disclose your child's protected health information to provide, coordinate or manage your child's

health care and any related services. This includes disclosure to your physician or other health care providers who will

become involved in your child's care

2. 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 in

writing. Your request should include a specified period of time for information sharing.

Required by Law

We may use or disclose your child's protected health information if law or regulation requires the use or disclosure. We will notify the appropriate government authority if we believe the patient has been a victim of abuse, neglect or domestic violence.

Health Oversight

We 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 healthcare

system, government benefit programs, other government regulatory programs and civil rights laws.

Legal Proceedings

We may disclose protected health information during any judicial or administrative proceeding, in response to a court order or

administrative tribunal (if such a disclosure is expressly authorized), and in certain conditions in response to a subpoena, discovery request or other lawful purposes.

Parental Access

We 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 Permission

In some circumstances you have the opportunity to agree or object to the use or disclosure of all or part of your child's protected health information. Since this service may be provided in a natural environment, others present during a session such as family members, friends or day care providers may hear health information regarding your child. Please notify your therapist if you do not want your child's protected health information to be discussed.

Your rights regarding your Child's Health Information

You 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 billing

records.

2. You may ask us not to use or disclose any part of your child's health information for treatment, payment or health care

operations. Your request must be made in writing. This request will be honored if we mutually agree that the restriction will

not harm your child.

3. You may request that we communicate with you using alternate means. We will not ask the reason for your request and

will 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 to

your child's protected health information as long as we are responsible for and maintain this information. While we will

accept 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 protected

health information. This right applies to disclosures made for purposes other than treatment, payment, or health care

operations 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 authorized

by you to family members or friends involved in your child's care, or for notification. The right to receive this information is

subject to additional exceptions, restrictions and limitations as described earlier in this notice

Federal Privacy Laws

This 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. These laws have been taken into consideration in developing policies and this notice of how we will use and disclose your child's protected information.

Complaints

If you believe these privacy rights have been violated, you may file a written complaint with the Department of Health and human Services. No retaliation will occur against you for filing a complaint.

* This notice is effective in its entirety as of November 1st 2015.

I have read On Target Pediatric Therapy's Notice of Privacy Practices (above), have reviewed it and agree to it.

Guardian Signature   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 understand that conflicts can happen and you may need to cancel an appointment. We respectfully ask that you confirm all cancellations AT LEAST 24 hours before your scheduled appointment/s. Failing to do so will be considered a “no show” and may result in a $50 non-refundable cancellation fee.

Additionally, if you arrive for your session more than 10 minutes late, you may be charged a late fee of $50 and the session may need to be rescheduled based upon the discretion of On Target Pediatric Therapy.

Our therapists want to be available for your child's needs. When a client does not show up for a scheduled appointment, another client loses an opportunity to be seen. Moreover, your own child may not make progress if he or she does not attend therapy consistently.

If you cancel your appointment 2 times within 8 weeks WITHOUT rescheduling, your child will be moved to a “flex schedule”. That means you can call in for weekly appointments and we will put you in if there is an open time slot, but your child will not have a consistent spot on the schedule. When a parent calls in for 4 consecutive weeks, the child can be moved back to a permanent spot in the schedule if a spot is available. Please note that an appointment is NOT considered canceled if it is successfully rescheduled within the week.

Please note that 2 no-shows in total, may result in your child being removed from the schedule.

Thank you for being a valued client and for your understanding and cooperation as we implement this policy. This policy will enable us to open otherwise unused appointments to better serve the needs of more families.

I have read and agree to On Target Pediatric Therapy's cancellation/late arrival policy.

Guardian Signature Signature* Date Date*   
   

We ask your cooperation by coming to the office prepared to pay for services rendered. All co-payments are collected at the time of service (before start of session). In addition, due to the growing trend toward high deductible plans, please be aware that we will collect an ESTIMATED payment for our services based on your insurance information at the time of checkin. Should your insurance pay for these services in full, we will refund your payment upon receipt of the insurance payment.

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.

Insurance coverage can change mid-treatment. Please make sure that you are aware of any changes to your child’s insurance and be aware that any services that are provided are your financial responsibility if we are not informed of 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.

Guardian SignatureSignature*    Date Date*          

In agreeing to receive care provided by On Target Pediatric Therapy LLC and to use the facilities provided therefore located at 2012 Harobi Drive, Tucker, GA 30084, 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 Signature   Signature*   Date    Date*     

Patient Name   First Name*   Last Name*   

Patient Date of Birth   Date*   

Insurance company*       

Guardian Name   First Name*   Last Name*   

Guardian Date of Birth   Date*   

Relationship to Patient   *   
   
Guardian Signature    Signature*        Date   Date*