Step By Step Consent Forms

Step by Step Pediatric Therapy Services

Consent Forms
Welcome to Step by Step Pediatric Therapy Services! In order to begin your child's therapy, please review and sign the forms below. Please bring a copy of your insurance card and ID to the appointment. We look forward to seeing you!
Demographic Information

Please indicate who may be bringing your child to subsequent therapy sessions and what information can be communicated with them in the form below:
Child's Name*
Date of Birth*

MonthDayYear
Date
Parent's Name*
Address*
Parent Phone Number*
Please enter a valid phone number.
Parent Work Phone
Please enter a valid phone number.
Parent Email Address
example@example.com
Additional Parent's Name
Additional Parent Address (if different)
Additional Parent Phone
Please enter a valid phone number.
Additional Parent Work Phone
Please enter a valid phone number.
Additional Parent Email Address
example@example.com
In the space below, please list anyone other than parent or guardian and check the appropriate box for permissions granted.
Name
Relationship
Phone Number
Please enter a valid phone number.
Type of permission for this contact:

Schedule and attend appointmentsReceive and provide disclosure of medical informationMake a medical decision in event of emergency
Name
Relationship
Phone Number
Please enter a valid phone number.
Type of permission for this contact:

Schedule and attend appointmentsReceive and provide disclosure of medical informationMake a medical decision in event of emergency
Please list your child's emergency contact*
Relationship*
Phone Number*
Please enter a valid phone number.
Background Information

Please provide the following information regarding the purpose of your visit with us:
What brings you to Step by Step Pediatric Therapy Services?*
Who referred your child for therapy?*
Does your child have a current IEP or IFSP?*

YesNo
If yes, what services does your child receive?
Does your child currently see any medical specialists?*

YesNo
If yes, what specialists?
List any medical history/illnesses:*
List any surgeries and dates:
List any allergies:
List any medications and dosages:
Signature of parent/guardian*

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Date*

MonthDayYear
Date
Please review the Notice of Privacy Practices and Permission to Evaluate and Treat, and sign below.
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. Obtain payment from third-party payers. Conduct normal healthcare operations such as quality assessments and audits.

I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Private Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations.

PERMISSION FOR EVALUATION AND THERAPY TREATMENT

I give Step by Step Pediatric Therapy Services permission to evaluate and provide therapy to the above name child:
Child's Name*
Date of Birth*

MonthDayYear
Date
Print Name of Parent/Surrogate or Legal Guardian*
Signature*

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Date*

MonthDayYear
Date
CONSENT FOR THE USE OF UNENCRYPTED ELECTRONIC DATA SHARING

At your request, you have chosen to communicate personally identifiable information concerning your treatment by e-mail or text message without the use of encryption.

This includes sending appointment reminders via e-mail or test message. Email reminders may contain patient or clinic information such as, but not limited to, patient first name and clinic location. Sending personally identifiable information by e-mail or text message has a number of risks that you should be aware of prior to giving your permission. These risks include, but are not limited to, the following: E-mail and text messages can be forwarded and stored in electronic and paper format easily without prior knowledge of the parent. E-mail and text messages senders can misaddress an e-mail, and personally identifiable information can be sent to incorrect recipients by mistake. E-mail sent over the Internet without encryption is not secure and can be intercepted by unknown third parties. E-mail content can be changed without the knowledge of the sender or receiver. Backup copies of e-mail or text messages may still exist even after the sender and receiver have deleted the messages. Employers and online service providers have a right to check e-mail sent through their

E-mail can contain harmful viruses and other programs.

Note: E-mail/Texting contact is for your benefit only. Information is not shared without additional consent from you. However, the exchange is not inherently secure.
Patient Name*
Date of Birth*

MonthDayYear
Date
Email
example@example.com
Cell Phone
Please enter a valid phone number.
Signature

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Date

MonthDayYear
Date
Payment Agreement
Name of Child*
Date of Birth*

MonthDayYear
Date
Name of Parent/Guardian*
I understand I am responsible for payment to Step by Step (SBS) for office visits. Co-payments are due at the time of service. Other patient liabilities will be billed after submitting to insurance.
Initial*
I agree to give SBS at least 24 hours notice when canceling an appointment, with exceptions made at the discretion of the therapist. If I do not give sufficient notice when canceling or I miss an appointment, I understand that I will be responsible for a $50 visit fee.
Initial*
Parent/Guardian Signature*

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Date*

MonthDayYear
Date
*For your convenience, we accept Visa and MasterCard. Please note that some flexible spending account debit cards cannot be processed; contact your card's administrator to ensure SBS is an approved provider.
Appointment Reminder Consent
Complete this form and sign below to give your permission for Step by Step to provide automatic appointment reminder service by email or by cell phone text message.
Date

MonthDayYear
Date
Name of Child
Please select one of the options below:

Step by Step may send cell phone text messages to confirm my upcoming appointments to provided cell phone number. I recognize that normal text messaging rates may apply.Step by Step may send email messages to confirm my upcoming appointments to my email address.
Email for appointment reminders:
example@example.com
Cell phone for appointment reminders:
Please enter a valid phone number.
We cannot set your account up to send email text message reminders without knowing your cell phone carrier. Please indicate your carrier below, if you would like text message reminders:

ALLTelAT&TBoost MobileCingularCricket WirelessMetrocallMetroPCSNextelQwestSprint PCST MobileUS CellularVerizonVirgin Mobile
Signature of Parent/Guardian

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Date

MonthDayYear
Date
Selective Release Form

This form is optional.
Complete this form and sign below to give your permission for Step by Step to exchange information with anyone aside from your pediatrician.
Patient's Name
Date of Birth

MonthDayYear
Date
I give my consent to Step by Step Pediatric Therapy Services to exchange information with
Type of information to be shared
I understand that this release is valid as long as the patient listed above is serviced by Step by Step Pediatric Therapy Services.

This consent shall not be used for the release of confidential, HIV-related information without additional specific consent.
Name of Parent/Surrogate or Legal Guardian
Signature

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Date

MonthDayYear
Date
INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS
This document contains important information about resuming in-person services in light of the COVID- 19 public health crisis. Please read carefully.

Decision to Meet for In-person Visits Step by Step has re-opened for in-person visits with safety protocols in place. If there is a resurgence of the pandemic or if other health concerns arise, Step by Step may return to exclusively offering visits via telehealth for everyone's well-being. If you decide at any time that you would feel safer staying with, or returning to, telehealth services, Step by Step will respect that decision, as long as it is feasible and clinically appropriate. Reimbursement for telehealth services, however, is determined by the insurance companies and applicable law.

Risks of Opting for In-Person Services By signing this consent, you understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk This risk may increase if you travel by public transportation, cab, or ridesharing service. You agree not to hold Step by Step responsible if exposure does occur.

Your Responsibility to Minimize Your Exposure To obtain services in person, you agree to take certain precautions which will help keep everyone safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in necessitating a return a telehealth arrangement.
Step by Step may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will inform you of any necessary changes.

Our Commitment to Minimize Exposure SBS has taken steps to reduce the risk of spreading COVID-19 within the office and we have posted our efforts on our website and in the office. Please let us know if you have questions about these efforts.

In Case of Illness We are committed to keeping you, SBS providers and all of our families safe from the spread of this virus. If you show up for an appointment and SBS staff believe that you have a fever or other symptoms, or believe you have been exposed, we will have to require you to leave the office immediately. We can follow up with services by telehealth as appropriate. We will work with the local health department to notify you in the case of a positive test for a provider from SBS.

Your Confidentiality in the Case of Infection If you have tested positive for COVID-19, SBS may be required to notify local health authorities that you have been in the office. If this is necessary, SBS will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits. By signing this form, you are agreeing that SBS may do so without an additional signed release.

Informed Consent This agreement supplements the general consent for services that were signed at the beginning of your child's therapy. Your signature below shows that you agree to these terms and conditions.
Patient Name*
Date of Birth*

MonthDayYear
Date
Parent/Guardian Signature*

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Date*

MonthDayYear
Date
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Step by Step Pediatric Therapy Services

Demographic Information

Background Information

Please review the Notice of Privacy Practices and Permission to Evaluate and Treat, and sign below.

Payment Agreement

Appointment Reminder Consent

Selective Release Form

INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS