Client Information Packet

revised 9/2015

Client Information Packet

Thank you for considering Therapy 4 Kids as a therapy provider for your child! We are excited to work with you and your family! Please complete the following pages along with submitting a copy of the front and back of your insurance card and return to us

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Our mission is to provide services that facilitate the greatest level of independence at each stage of development. We strive to enhance the independence of children across all settings of life: Home, School, and Play.

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Please complete this packet and return to:

Therapy 4 Kids

7055 Mexico Rd Suite 1601

St. Peters, MO 63376

or

Fax to 636-323-2155

or email it to

Phone-636-866-1341

Did you remember to….

o  Attach a copy of the front and back of your insurance card

o  Sign all attached paperwork including HIPPA, consent to bill & treat, privacy policy

o  Add any additional medical information you have on your child

o  Complete the credit card on file form

Client Information
Patient Name:______
Patient DOB:______
Patient Address:
______
______
Guardian/Legal Representative Name: ______
Relationship:______
Email:______
Phone #:______
Referring Doctor:______
Phone #:______
Fax #:______
Insurance Provider:______
Insured’s Name:______Relationship to Patient:______
Insured’s Date of Birth:______
Insured’s Address (if different):
______
______
Insured’s ID #:______
Insured’s Group #:______
Patient ID #:______
Employer:______
______
A copy of our privacy practices can be found on our website at therapy4kidsllc.com.

Client Acknowledgement

I have received Therapy 4 Kid’s Notice of Privacy Practices, which describes this agency’s methods for protecting the privacy of my health information that is used in providing health care services to me.
Signature:______
Date:______

CONSENT TO TREATMENT

Consent for Therapy Treatment

I ______give consent for THERAPY 4 KIDS to begin Therapy Treatment (PT, OT, ST) for my child .

Consent for treatment will remain in effect for the duration of therapy services.

Initial:______

CONSENT TO BILL FOR SERVICES

Consent To Bill For Treatment

I authorize THERAPY 4 KIDS to contact my insurance company to determine my child’s eligibility for benefits. I authorize THERAPY 4 KIDS, LLC to bill insurance for therapy services provided to my child and to provide my insurance with treatment information (evaluations, progress notes, etc.) as may be required for payment. It is my responsibility to understand my insurance benefits. I understand that any therapy services not paid for by my insurance carrier will be billed to me directly and will be my responsibility. The Credit card on file form will serve as my payment to be used on all remaining balances if unpaid within the 15 days of the original invoice.

Initial:______

Therapy bills will be sent as processed from your insurance company. Payment is due 15 days from the date of the invoice. Payment not made within that timeframe will accrue a $40 late fee and the $40 fee will be accrued if the card on file is not updated as needed. This is the responsibility of the insured. If the Credit card on file is active then all bills will be paid using the credit card on file. Therapy bills not paid within a 3 month time period will be sent to a collection agency. Any returned checks will result in a $25 fee to the client.

Initial:______

The therapy service will be cancelled and the client will be assessed a $40 fee for all no shows with a scheduled appointment. Three (3) no-shows and or combination of cancelations “without a 24 hour notice” in 3 weeks will forfeit services from Therapy 4 Kids. A 24 hour or greater cancellation notice is appreciated.

Initial:______

Changes must be requested in writing to any of the above statements. All requests to terminate treatment must be made in writing to the following address:

THERAPY 4 KIDS

7055 Mexico Rd Suite 1601

St. Peters, MO 63376

I have read and understand the above conditions.

Signature:______Date:______

Relationship to Patient:

Medical Information Release Form

(HIPAA Release Form)

Name: ______Date of Birth: _____/____/_____

Release of Information

I authorize the release of information pertinent to my child’s treatment including the diagnosis, examination and report,visit notes and claim information. This information may be released to:

o  Spouse______

o  Child(ren)______

o  Physician______

o  Insurance______

o  Other______

o  Information is not to be released to anyone.

This Release of Information will remain in effect until terminated by me in writing.

Signed: ______Date: ____/____/_____

PATIENT MEDICAL INFORMATION FORM

*This form is helpful for you to fill out completely. This form helps our staff with any questions we may receive from insurance or the therapists who are treating your child. Please fill out and add additional information as necessary.

Child’s Name: ______Date of Birth: ______

Pediatrician ______Phone number______Fax______

Other specialist(s) name and number we can contact: ______

______

Past Hospitalizations/Surgeries:

1. Reason/Diagnosis: ______

Date of Hospitalization/Surgery: ______

2. Reason/Diagnosis: ______

Date of Hospitalization/Surgery: ______

Please list any other significant medical issues: ______

______

Please list any medications and dosage the child is currently taking (include supplements):

______

Please list any known drug or food allergies and the nature of the reaction (rash, swelling, etc.)

______

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Please circle yes if your child has had the following illnesses:

Detailed Information

Heart Disease Yes/No ______

Hypertension (high blood pressure) Yes/No ______

Cancer Yes/No ______

Asthma Yes/No ______

Diabetes Yes/No ______

Seizure Disorder/Convulsions Yes/No ______

Thyroid disease/Lupus/Autoimmune Disease Yes/No ______

Hearing Loss/Deafness Yes/No ______

Kidney Disease Yes/No ______

Tuberculosis Yes/No ______

Developmental delay Yes/No ______

Other genetic conditions/diseases Yes/No ______

Fractures Yes/No______

Any other information you would like us to know about your child ______

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Card on File: Authorization Form

Information to be completed by cardholder:

The undersigned agrees and authorizes medical practice to save the credit card indicated below on file. If bills are not paid within 15 days of the mailed invoice date (included but no limited to any co pays, deductibles, no shows, damage to equipment borrowed, etc.), the credit card on file will be charged. By signing this you agree to these terms.

Medical Practice: Therapy 4 Kids

Patient’s Name: ______

Name as it Appears on the Credit Card: ______

Type of Credit Card: ☐ Master card ☐ Visa ☐ Discover ☐ Amex

Credit Card Number ______

CVV : ______

Expiration Date: ______

I, ______authorize the above medical practice to process the above credit card as “Card on File”. I understand this authorization will remain in effect until the expiration of the credit card account. Patient may also revoke this form by submitting a written request to the medical practice after all outstanding bills are paid. Please see previous pages of the Client Information Packet for additional details.

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Cardholder’s Signature Date

1