TW-Patient Packet (2022)

TW-Patient Packet

Therapy Works, PC is a paperless practice that uses HIPAA-compliant electronic health record systems. All information provided will be confidential.

This form will take approximately 15 minutes to complete. Please have your insurance card handy while completing the form as you will be asked to take a picture and upload it to a secure link.

Various consent forms and questionnaires will require an electronic signature

Please do not print these forms. Please fill them out online at least 24 hours before your appointment.

For questions, please call (770) 995-2379.

Thank you!

My child is a:*

NEW patientCONTINUING patient

Patient Demographics
Name of Child*
Date of Birth*

MonthDayYear
Date
Age*
Gender

BoyGirl
Parent/Guardian Name*
Contact Number*
Email Address*
example@example.com
Address*

Home Address

Street Address Line 2

CityState

Zip
Doctor's Name*
Doctor's Phone Number
Diagnosis, if any:
I DO give permission for Therapy Works to treat my child.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

I have carefully completed the above and certify that I have provided correct bill information to be used by Therapy Works, PC.

I agree to provide a copy of my insurance and/or Medicaid card to Therapy Works.

I agree to immediately notify Therapy Works of any changes to the above billing information.

I agree that failure on my part to provide up to date insurance and/or Medicaid information on my child will result in Therapy Works directly billing me for all charges incurred and Therapy Works will not back bill any charges incurred.

I understand that I am ultimately responsible for all charge incurred by my child.
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date

PATIENT CONSENT FOR USE/DISCLOSURE OF HEALTH CARE INFORMATION
Patient's Name
Date of Birth

MonthDayYear
Date
Parent's Name
Phone Number
I understand that the patient’s health information is private and confidential. I understand that Therapy Works, PC tries very hard to protect the patient’s privacy and preserve the confidentiality of the patient’s personal health information.

I understand that Therapy Works, PC may use and disclose the patient’s personal health information to help provide health care to the patient, to handle billing and payment, and to take care of other health care operations. [* In general, there will be no other uses and disclosures of this information unless I permit it. I understand that sometimes the law may require the release of this information without my permission. These situations are very unusual. One example would be if a patient threatened to hurt someone.]

Therapy Works, PC has a detailed document called the “Notice of Privacy Practices”. It contains more information about the policies and practices protecting the patient’s privacy. I understand that I have the right to read the “Notice” before signing this agreement.

Therapy Works, PC may update this “Notice of Privacy Practices”. If I ask, Therapy Works, PC will provide me with the most current “Notice of Privacy Practices”.

Under the terms of this consent, I can ask Therapy Works, PC to limit how the patient’s personal health information is used or disclosed to carry out treatment, payment or health care operations. I understand that Therapy Works, PC does not have to agree to my request. If Therapy Works, PC does agree to my request, I understand that Therapy Works, PC would follow the agreed limits.

I may cancel this consent in writing at any time by doing one of the following:

I. Signing and dating a form that Therapy Works, PC can give me called “Revocation of Consent for Use and Disclosure of Health Care Information”; or

II. Writing, signing, and dating a letter to Therapy Works, PC. If I write a letter, it must say that I want to revoke my consent to authorize the use and disclosure of the patient’s personal health information for treatment, payment, and health care operations.

If I revoke this consent, Therapy Works, PC does not have to provide any further health care services to the patient.

My signature below indicates that I have been given a chance to review a current copy of Therapy Works, PC “Notice of Privacy Practices”. My signature means that I agree to allow Therapy Works, PC to use and disclose the patient’s personal health care information to carry out treatment, payment, and health care operations.
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date

ATTENDANCE POLICIES AND PROCEDURES
Patient's Name
Date of Birth

MonthDayYear
Date
Parent's Name
Phone Number
We realize attending therapy is a huge commitment for you and your child and we want to make sure your child receives full benefit from this commitment. In order for this to occur, please note the following:
1.      It is very important that you make it to all appointments. Consistent treatment is vital for your child’s progress. Most insurances and Medicaid review billing and notes to make sure the children are attending therapy regularly and they take this into consideration when deciding if they will continue to cover therapy.

2.      Your therapist is committed to your child for the therapy times you have agreed to. Do not schedule other appointments (doctor, dental, school meeting, etc.) during this time. Be considerate of the therapist’s time and commitment. Notify them at least 24 hours in advance if you cannot be at therapy. Please contact your therapist at 770-995-2379 or another number they may provide at least 24 hours before your session to cancel (exceptions- if your child wakes up sick the morning of therapy).

3.      Please be on time for your appointment to ensure a full therapy session. Please consider traffic, weather etc. when scheduling a therapy time.

4.      If you do not come and do not call (no show) or if too many visits are missed, it will be necessary to discontinue therapy. If your child is not at therapy, we cannot make progress so it is better to stop therapy until your child is able to consistently attend.

5.      If you are going to miss 3 weeks or longer, your child will not be discharged but your scheduled time slot may be filled. We will do our best to offer you another time when you return. We often have children waiting for therapy and want to be fair to all.
Please understand these policies are for your child to have a successful experience here with us. We make every effort to make your child's needs our top priority so they can make progress. We need to work together to make this happen. Thank you so much for giving us the opportunity to work with your child.

Please contact us at 770-995-2379 if you would like to discuss your child's therapy at Therapy Works or have any questions or
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date

PROVIDER SWITCH FORM
Patient's Name
Date of Birth

MonthDayYear
Date
Parent's Name
Phone Number
Has your child received any occupational, physical or speech evaluations or treatments in the last six months?*

YES.NO, Please sign and date below.
If your child has received any therapy in the last 6 months (evaluation and/or treatment), please check all that apply:*

Occupational TherapyPhysical TherapySpeech Therapy
Occupational Therapy Name of Facility*
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Physical Therapy Name of Facility*
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Speech Therapy Name of Facility*
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
If you wish to change therapy providers, your insurance may require the following statement:

My child will no longer be receiving therapy/therapies at the facility/ facilities above and will be receiving this therapy at THERAPY WORKS, PC
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date
If your child is in Babies Can't Wait (BCW), please email current IFSP to office@therapyworkspc.com.
If your child is in Special Education, please email current IEP to office@therapyworkspc.com.
Should be Empty:

TW-Patient Packet

Patient Demographics

I DO give permission for Therapy Works to treat my child.

IF YOUR CHILD IS YOUNGER than 3 years old:

IF YOUR CHILD IS 3 YEARS OLD AND OLDER:

THERAPY HISTORY

INSURANCE INFORMATION

MEDICAID /CARE MANAGEMENT ORGANIZATION INFORMATION (IF APPLICABLE)

ASSIGNMENT OF BENEFITS

PATIENT CONSENT FOR USE/DISCLOSURE OF HEALTH CARE INFORMATION

ATTENDANCE POLICIES AND PROCEDURES

LETTER OF ATTESTATION

PROVIDER SWITCH FORM