“therapy with a purpose” · activity training (adl), ot intensive programs, oral motor/feeding...

800 N. Watters Rd., Ste. 150 21703 Kingsland Blvd., Ste. 100 Allen, TX 75013 Katy, TX 77450 Tel: (469) 675-3153 Tel: (281) 769-1015 Fax: (469) 675-3154 Fax: (281) 717-8947 Email: [email protected] Email: [email protected]

Dear New Family,

Welcome to Cutting Edge Pediatric Therapy (CEPT)! We are excited to have the opportunity to assist your child in their therapy care. Our therapists strive to provide the highest quality treatment using the most current and innovative therapy treatments currently available, in a professional and caring manner. We are committed to helping you identify your child’s needs and achieve their goals, while striving to meet our mission, “Therapy with a Purpose”. Our sincerest belief is that every intervention will have a purposeful outcome for all of our clients.

CEPT provides therapy for both children and adults. We specialize in the individualized treatment of each patient and their family structure. Our treatment modalities include Receptive and Expressive Language, Language Processing, Articulation, Phonological Processes, Fluency, Augmentative Communication, Feeding/Swallowing, Craniosacral/Myofacial Release Therapy, Fine and Gross Motor Skills, Functional Activity Training (ADL), OT Intensive Programs, Oral Motor/Feeding Therapy, The Listening Program, TLP/Bone Conduction, Therapeutic Listening Program, and Interactive Metronome. Our therapists specialize in multi-types of treatment techniques for a multitude of systems. CEPT is also a teaching clinic so on occasion students from various colleges may accompany your child's therapist, observe treatment and have sight of their notes. Please let me, your child’s therapist, or our office staff know if this is a concern for you.

Enclosed is the General Patient Intake Packet. Please read the information carefully, fill out all the documents, and return to us at least 2 days prior to your child’s evaluation appointment. Please note that payment is due at the time of the evaluation. We accept cash, checks, Visa, MasterCard, Discover, and American Express. Checks are to be made payable to CEPT. Should you wish to pay by credit card, please have your driver's license and credit card with you at the time of your appointment. A photo copy of both will be kept on file with your Credit Card Policy Agreement form.

CEPT is an in-network provider with Blue Cross Blue Shield (as well as traditional Medicaid at the Allen location) and files out of network insurance claims with most insurance carriers. At this time, it will be the patient’s responsibility to determine the proper coverage for all other insurance carriers and to contact their insurance company regarding their out-of-network deductible and benefits prior to the appointment. You will need to pay in-full for each appointment and receive reimbursement from your insurance company in accordance with the terms of your contract with them. Once we receive your insurance information, we can schedule your child’s evaluation. Your child’s initial evaluation will last approximately two hours. Your therapist will then schedule a parent meeting to discuss the evaluation and treatment options with you.

I can never effectively communicate our passion and enthusiasm for the innovative ways that we are reaching patients through our treatments here at CEPT. It is our sincere desire to partner with you and your child as we start this new and exciting journey together.

With kind regards,

Your Cutting Edge Pediatric Therapy Team

“Therapy With A Purpose”

Patient Intake Form


Patient Intake Information – For All Services **All Fields Required**

Patient Name ___________________________________________ Date of Birth ___________________ Gender_______________ Age__________ Preferred Name ____________________________ Marital Status of Parents_____________________ Please check or X all therapy services that apply:

Occupational Therapy: ____________ Physical Therapy: _____________ Speech Therapy: _______________

Pediatrician/Physician Name ____________________________________ Phone # ________________________ Fax# _______________________ Pediatrician/Physician Address___________________________________________________ City__________________ State/Zip_____________ Previous OT/PT/Speech Treatment ______________ When/ Where/ last date of service________________________________________________ Date of Last Medical Doctor Appointment______________________________________ Previous Evaluation: YES / NO / UNSURE Describe Present Problem: _________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ Has there been any significant change in the last six months? ____________________________________________________________________ Child lives with______________________________________________ Siblings/Ages ________________________________________________

Is child attending school? __________________________________ Where? ________________________________________________________ How did you hear about Cutting Edge Pediatric Therapy? _______________________________________________________________________ Does your child have any medical diagnoses or medical concerns that CEPT should be aware of? ________________________________________ ______________________________________________________________________________________________________________________ Does your child take any medications? ______________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________

Allergies/Restrictions ____________________________________________________________________________________________________ ______________________________________________________________________________________________________________________

Child’s Daily Routine _____________________________________________________________________________________________________


______________________________________________________________________________________________________________________ Child’s Interests _________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ Does your child have any behavioral concerns? (Biting, Pinching, Kicking, etc.) If so, please specify: ______________________________________ ______________________________________________________________________________________________________________________ Parent Goals/Notes ______________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ Does your child have Special Education or Therapy services in school? ____________________________________________________________ If yes, what services are they receiving? _____________________________________________________________________________________ How often? ____________________________________________________________________________________________________________ Individual or group setting? _______________________________________________________________________________________________

Parent/Guardian Information

Responsible Party’s Name __________________________________________ DOB ___________________ Relationship ____________________

Drivers License # _______________________ State Issued ________________ Email Address __________________________________________

Home Address ________________________________________________________ City _______________________ State/Zip _______________

Home # _________________________________ Cell #_______________________________ Work # ____________________________________

SS#_____________________________ Employer___________________________________________ Title_______________________________

Guardian _____________________________________________ DOB_____________________ Relationship _____________________________

Drivers License # _______________________ State Issued ________________ Email Address __________________________________________

Home # ________________________________ Cell #__________________________________ Work # __________________________________

Emergency Contact___________________________________ Phone # ______________________ Relationship___________________________

Parent’s Marital Status: __________________________________________________________________________________________________

Insurance Information Required

Insurance Co. ___________________________ Claims Phone # _______________________ Group # _______________ Policy #______________ Claims Address _____________________________________________________ City _______________________ State/Zip _________________

Insurer ______________________________ DOB _________________ SS# __________________ Relationship to Patient____________________


Medical History / Developmental History

Patient Name: ____________________________ Name of Person Completing Form: ________________________ Some of these questions may not reflect the age of the person you are describing. Please skip these if they do not pertain to

your child. You may add narrative on the back for a more specific description of your child.

Mother’s Health History

(Is child adopted ______) (If so, at what age? _________) (Specify country? ________________)

1. Infections/illness during pregnancy? YES NO

Describe _____________________________________________________________________________________________

2. Have any shocks or abnormal stresses during pregnancy? YES NO

Describe _____________________________________________________________________________________________

3. Did Mother’s water break 24 hours before delivery? YES NO

Describe _____________________________________________________________________________________________

4. Did Mother develop Toxemia or high blood pressure? YES NO

Describe _____________________________________________________________________________________________

5. Did Mother have any complications during labor and/or delivery? YES NO

Describe _____________________________________________________________________________________________

6. Mother’s age at delivery _____________ Length of pregnancy _______________

7. Child’s birth weight ___________________ Weight upon discharge from hospital __________________

8. Apgar Scores: 1 minute ______________________________ 5 minutes ____________________________

Child’s Birth YES NO COMMENT

1. Full Term _____ _____ _____________________________________________

2. Premature _____ _____ _____________________________________________

3. Cesarean section _____ _____ _____________________________________________

4. Require Pitocin _____ _____ _____________________________________________

5. Breech (feet first) _____ _____ _____________________________________________

6. Face presentation _____ _____ _____________________________________________

7. Transverse (sideways) _____ _____ _____________________________________________

8. Have cord wrapped around neck _____ _____ _____________________________________________

9. Require forceps _____ _____ _____________________________________________

10. Have any birth injuries _____ _____ _____________________________________________

11. Require a fetal monitor _____ _____ _____________________________________________

12. Have insufficient oxygen _____ _____ _____________________________________________

13. Cried right away _____ _____ _____________________________________________

14. Require intensive care/hospitalization _____ _____ If so, how long_________________________________

15. Respiratory problems _____ _____ _____________________________________________


YES NO COMMENT

16. Need a respirator _____ _____ If so, how long_________________________________

17. Small for gestational age _____ _____ _____________________________________________

18. Heart defect _____ _____ _____________________________________________

19. Require an exchange transfusion _____ _____ _____________________________________________

20. Jaundiced _____ _____ If so, how long_________________________________

21. Seizures _____ _____ _____________________________________________

22. Infections at birth _____ _____ _____________________________________________

23. Surgery at birth _____ _____ _____________________________________________

24. Feeding problems at birth _____ _____ _____________________________________________

Has your child ever been hospitalized? _______________ If yes, please complete the below section,

When How Long Reason

_________________________ ___________________ ____________________________________________________

_________________________ ___________________ ____________________________________________________

_________________________ ___________________ ____________________________________________________

_________________________ ___________________ ____________________________________________________

DEVELOPMENTAL HISTORY

Age when child: (If you cannot remember specific time, please indicate if it occurred at the expected time or if it was delayed)

Sat up alone _______Crawled ________ Walked _________ Toilet trained _______Dressed self/Tied shoes __________

Fed self independently _________Weaned from bottle/breast ________ Tube feedings (Y/N) ____________________

Is the child left or right handed? ________ Able to use: ______ Open Cup ______ Spoon _______ Straw

Any difficulty? (Y/N) ______ Swallowing ______Chewing ______Drinking ______Blowing _____Drooling

Food allergies: _____________________________________________________________________________________

Favorite Foods: _____________________________________________________________________________________

Aversive Foods (if any): ______________________________________________________________________________

Attention span-for self-directed activities: _________________ Adult-directed: _________________________________

Does your child respond typically to (Y/N): ______Light ______Sound ______People ______ Food textures/Consistencies

Does your child (Y/N): ______Play with others Who? _______________________________________________

Does your child eat well? _________Typical feeding schedule_______________________________________________

Does your child sleep well? _______ Typical sleep schedule _______________________________________________

Bowel/Bladder function _____________________________________________________________________________

Does your child:

Cry appropriately? ____________ Laugh? __________ Smile? ______________

Make wants/needs known? ____________ How? _________________________________________________________

Does your child show unusual behavior (explain)? ________________________________________________________

Date of most recent Hearing/Vision Screening ____/______/_______ Results: __________________________________

____________________________________________________________________________________________________

SOCIAL DEVELOPMENT

Relationships with siblings: ___________________________________________________________________________

__________________________________________________________________________________________________

Relationship with peers: _____________________________________________________________________________

__________________________________________________________________________________________________

Number of regular playmates: __________ Ages: _________ Genders: _______________________________________

Activities shared with parents and siblings: _______________________________________________________________

How does your child handle:

Frustration: ________________________________________________________________________________________

Conflict: __________________________________________________________________________________________

Separation: ________________________________________________________________________________________

Regular responsibilities: ______________________________________________________________________________

Favorite places: ____________________ People: ___________________Toys:__________________________________

Snacks: _____________________ Activities: ______________________TV programs:_____________________________

What motivates your child most? _______________________________________________________________________

__________________________________________________________________________________________________

What discipline methods work best? ____________________________________________________________________

__________________________________________________________________________________________________

SCHOOL HISTORY

Child’s Current School and Grade: _____________________________________________________________________

Child’s performance educationally: _____________________________________________________________________

Receiving special services at school: __________________________________________________________________

Does your child currently have an IEP: __________________________________________________________________

How does your child's teacher describe his/her performance? ________________________________________________

Has the teacher expressed any concern? If so, what? _______________________________________________________

__________________________________________________________________________________________________

Emotional History and Behavior

Give a brief description of the child’s personality. Begin by writing the one word which best describes the child. Please include

your child’s strengths and weaknesses. ____________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Has child ever been given a psychological evaluation? ________ When? __________ By whom? ______________________

What is the best thing about your child? ___________________________________________________________________

What concerns you most about your child? ________________________________________________________________

Is child primarily responsive to: People? ____________ Objects? _______________

Is child especially alert to: Movement? ____________ Noise? _________ Touch? _____________

Is child highly distractible? _____________ Hyperactive? ____________ Withdrawn? _____________________

Is child’s behavior consistent from day to day? ______________________________________________________________

Is child easily managed at home? ________________________________________________________________________

When fatigued, does your child sag? __________ Become irritable? _______________ Become excited? _______________

When placed under pressure or tension, is there any pattern of behavior, such as thumb sucking, nail biting, etc.? ________

_____________________________________________________________________________________________________

In which activities is child most successful? __________________________________________________________________

What are child’s hobbies? _______________________________________________________________________________

How does the child do with peers? ________________________________________________________________________

What is the relationship between father and child? __________________________________________________________

What is the relationship between mother and child? _________________________________________________________

What is the relationship between siblings and child? _________________________________________________________

Are there any family members with emotional, addictive or bipolar problems? ___________________________________

____________________________________________________________________________________________________

___________________________________________________________________________________________________

Does your child display any aggressive behaviors (i.e. Hitting, kicking, pinching, biting, melt downs)? If yes, please describe the

aggressive behavior detailing frequency and cause: ___________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

Any known precursors for negative behavior? _______________________________________________________________

How do you handle negative behavior? _____________________________________________________________________


NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you may have access to this information. Please review this carefully. Who Will Follow These Practices?

Protected Health Information (PHI) will be disclosed by CEPT and therapists.

These policies do not apply to information that CEPT and therapists receive while in a non-health care provider capacity.

These require CEPT, employees, and any third parties that participate to comply with the privacy rules while engaging in activities.

CEPT employees providing services are required to protect each patient’s PHI. This is information we have created or received relating to health conditions, all of the health care payments that identify you or provides basis to believe the information can identify you.

PHI does not include individually identifiable information contained in the Family Education Rights and Privacy Act and the Health Insurance Portability and Accountability Act (HIPAA).

We provide you with this notice to explain how, when, and why we disclose your PHI. We will not disclose any more than is necessary.

We reserve the right to change the terms of this notice at any time that will apply to what we already have. We will make the change in this notice and post a new one at CEPT locations and on the website.

How We May Disclose and Use Your Protected Health Information

Certain Uses and Disclosures Do Not Require Your Authorization for These Reasons: o For Treatment— It may also be disclosed to educational facilities, your referring physician, and

those participating in the delivery of health care. o For Payment—It may be disclosed so your services are billed and payment is collected properly.

We may tell the clinic about treatment to be received to obtain prior approval and determine if your plan covers treatment. We may discuss PHI with a pharmacist as well to determine correct dosage and administration of medical information.

o For Health Care Operations—It may be disclosed to review services to evaluate the performance of the staff and make sure all patients receive quality care. We may combine the PHI of several patients to determine if additional services need to be offered, which services are not needed, and if treatments are effective. Identifiable information may be removed for educational facilities to use.

o When Disclosure Is Required By Law—Under HIPAA, we must make PHI disclosures to the Secretary of the Department of Health and Human Services if the law requires us to do so. It is for them to investigate our compliance with the requirements of the Privacy Rule with HIPAA.

o For Public Health Activities—It may be disclosed if information is reported about births, deaths, various diseases, etc. to government officials collecting this information. Information will also be provided to necessary medical providers.

o For Health Oversight Activities—It may be disclosed to a health oversight agency for activities authorized by the law. This is necessary to assist government conduction of investigation or inspection of a health care provider or organization.

o For Research Purposes—It may be disclosed to approved researchers with reviewed and accepted protocols. This will include no unique identification of the subject of the information.


o To Avoid Harm—It may be disclosed when we believe it will prevent a serious threat to health and safety of a person or the public. We may provide PHI to law enforcement able to prevent or lessen harm.

o For Specific Government Function—It may be disclosed for military personnel or veterans for intelligence, counterintelligence, and national security purposes.

o For Workers Compensation Purposes—It may be disclosed to comply with these laws that benefit work-related injuries or illnesses.

o Appointment Reminders and Health-Related Benefits—It may be disclosed for reminders and give information about treatment alternatives or services we offer.

o Inmates—It may be disclosed about an inmate or the person having lawful custody. This is necessary to provide them with health care, protect their and others health and safety, and provide law enforcement on institution premises.

o To You or Your Personal Representative—It may be disclosed to your representative if you are a minor. We will obtain documentation that supports your representation prior to disclosure. We do have the right not to accept this person if we have reason to believe they are a danger to you in some form.

Uses and Disclosures with Prior Written Authorization: o In situations not referenced above, we will as for written authorization before using or disclosing

your PHI. If you choose to authorize PHI disclosure, you can later revoke the authorization in writing to stop any further disclosure.

What Rights You Have Regarding Your PHI (Protected Health Information)

To See and Get Copies of Your PHI—The request must be made in writing and we will respond to you within 30 days of receiving it. We may deny the request in writing in certain situations. We may also charge a fee for copying, mailing, or supply costs.

To Correct or Update Your PHI—If you think there may be a mistake or information is missing, you may submit a request in writing to change it and we will respond to it within 60 days. We may deny it if the PHI is complete and correct, not created by us, not allowed to be disclosed, or is not part of our records. If we approve it, we will make the change, tell you that we have, and make sure others know

To Get a List of the Disclosures We Have Made—We will respond within 60 days of your written request. This list will include disclosures made in the last 6 years unless you request a shorter time. It includes the date of disclosure, to whom it was disclosed, description of the information, and the reason for disclosure.

To Request Limits on Uses and Disclosures of Your PHI—A written request must be submitted to CEPT. It must tell us the PHI you would like to limit, the reasons why, and to whom the limits apply. We will consider this request but are not legally required to accept it.

To Choose How We Send PHI To You—You can request that we send information to an alternate address or by alternate means. We must agree to this request as long as it is reasonable and can easily provide the requested information. It must be submitted in writing to CEPT.

To Get a Paper Copy of this Privacy Notice—Request must be submitted or you may look on our website for a copy at www.cuttingedgepediatrictherapy.com

How to Complain About Our Privacy Practices

If you think we may have violated your privacy rights or you disagree with a decision made about access to your PHI, you may file a complaint with the CEPT Privacy Officer.

o We will take no retaliatory action against you if you file a complaint about our Privacy Practices. ____________________________________________ ___________________________________________ Signature of Patient or Personal Representative Date


Financial Agreement

BlueCross BlueShield, United Healthcare, Aetna, and Cigna Insurance Companies Cutting Edge Pediatric Therapy is an in-network provider with Blue Cross Blue Shield (BCBS) and files out-of-network insurance claims with United Healthcare (UHC), Aetna, and Cigna Insurance companies. Please notify us if your insurance company is not listed and we will research our ability to file your claims and provide treatment under your insurance plan. Patients are billed for their annual out-of-network deductible at the beginning of their plan’s calendar year. After the patient’s out-of-network deductible has been satisfied, the patient is responsible for the co-pay amount set by their insurance carrier. Patients are billed for the remaining balance after payment has been received from their insurance company. Any non-covered services are the financial responsibility of the patient. In the event that payment for a performed service is denied by the insurance carrier, it is the patient’s responsibility to pursue action with their insurance carrier, as the policy is a legal contract between the patient and the insurance company. If the insurance company does not pay claims within 60 days for any reason, I will be responsible for payments to Cutting Edge. If I do not honor this financial agreement and develop an outstanding balance, I will pay the charges within 30 days. I agree to an interest charge of 1.5% per month (18% per year) if my balance is not paid within 30 days. If payment is not made, I waive the right to confidentiality for the purpose of collection of the said fee. Any reasonable attorney fees and costs incurred by Cutting Edge Pediatric Therapy for the collection of the past due account shall be my obligation as well. For Other Carriers, There is no Insurance Coverage: If a patient has insurance carriers other than BCBS, UHC, Cigna or Aetna or has no insurance coverage, they are responsible for all charges incurred at the time of service. Co-payments, co-insurance, non-covered services and/or deductibles are the responsibility of the patient and are payable at the time of service. BY SIGNING THIS DOCUMENT, I UNDERSTAND THAT PAYMENT IS EXPECTED AT THE TIME OF SERVICE. I MUST PROVIDE A PHOTO COPY OF MY INSURANCE CARD ANNUALLY AND ANY TIME THAT I CHANGE INSURANCE PLANS. IT IS MY RESPONSIBILITY TO NOTIFY CEPT OF ANY CHANGES. I UNDERSTAND THAT I MAY BE RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY MY HEALTH PLAN WITHOUT LIMITATION OF THE OUT-OF-NETWORK OR IN-NETWORK DEDUCTIBLE, CO-PAYMENT AND/OR COINSURANCE AMOUNT. If your insurance policy has visit caps or limited visits, it is your responsibility to track these visits as they occur. If you have participated in occupational therapy visits with another provider during the insurance year, then you will need to include those visits. CEPT will attempt to track these visits, however, you as the customer receive more timely information from your insurance provider.


____________________________________________ __________________________________________

Parent/Legal Guardian Signature Date ____________________________________________ __________________________________________ Patient’s Name Date of Birth ____________________________________________ __________________________________________

HIPAA Privacy Officer Date


COMMUNICATION CONSENT FORM

I give permission to CEPT to contact me in the following methods regarding my private health information, evaluation, treatment, and appointments. I authorize CEPT to leave messages for me when I am unavailable. You will receive an email or text three days prior to your appointment as a reminder. If you are not receiving this or in the correct amount of time, please let us know. Home Phone (______) ____________________

Message with Information Message with call-back number only

Cell Phone (______) ____________________


Work Phone (______) ____________________


Text Messages (______) ____________________


Email ______________________________________

Message with Information Message with call-back number only I authorize CEPT and therapists to discuss my health care information with the contacts listed below. I understand that by leaving these spaces blank, I am indicating that I do not want information released to anyone else. Name Relationship to Patient Phone Number ____________________________________________________________________________________ ____________________________________________________________________________________ By signing, I acknowledge that I have read and understand these communication guidelines. I allow CEPT to contact me by these means and give permission to the people listed above to receive patient health care information. _________________________________________ _____________________________________ Patient, Guardian, Legal Representative Signature Date



CLINIC WELLNESS POLICY

Please do not bring your child (patient or sibling) into the Clinic if they are exhibiting any of the following medical health concerns:

Fever: Fevers are common in young children and are often a signal that something is wrong. If your child has a fever of 101.0 degrees Fahrenheit or higher, please keep him/her at home. If you child develops a fever of 101.0 degrees Fahrenheit or higher while at the clinic, the therapy session will end and your therapist will make every reasonable effort to reschedule the appointment. Our policy is that your child must remain fever-free for 24 hours before returning to the clinic, a policy agreed upon by local pediatricians. The 24 hours begins when your child’s fever has broken and remains in the normal range.

Diarrhea: Diarrhea due to illness is highly contagious. If your child has diarrhea, please keep him/her home. Please understand that germs from diarrhea can spread throughout carpet, toys, swings and direct contact. It is very difficult to keep these germs from spreading to other children. However, if this is a chronic condition for your child, please advise your therapist so that we can make the appropriate recommendations or accommodations.

Vomiting: If your child vomits while at the Clinic, you will be called to pick him/her up immediately. Please keep your child at home for 24 hours after the vomiting has stopped. When children return to therapy prematurely, there is a much higher rate of recurrence and contagiousness.

Severe Common Cold: Symptoms include, but are not limited to: bad cold with a hacking or persistent cough; green or yellow nasal drainage; and/or a productive cough with green or yellow phlegm. These symptoms may be present with or without a fever. Seasonal allergies are exempt from this policy.

Rash: A rash may be a sign of many illnesses such as measles or chicken pox. Please do not bring your child into the clinic until your doctor releases you to do so. Rashes due to non-contagious skin conditions are exempt from this policy. We do understand and empathize with parents when their children are ill. These policies are designed to be fair to the ill child and their family, as well as the healthy children and their families. Please understand that we love your children and strive to provide the best possible care for them. We hope to control the amount of illness at the Clinic and to keep everyone healthy and happy. If you have any questions or concerns, please do not hesitate to call us. Thank you!

____________________________________________

Printed Patient’s Name ____________________________________________ __________________________________________

Printed Parent/Guardian Name Date



AUTOMATIC CREDIT CARD BILLING AGREEMENT

CUTTING EDGE PEDIATRIC THERAPY (CEPT) can process your payment via MasterCard, Visa, Discover, and American Express (credit or debit) and personal checks. Payment is due upon receipt of your invoice at the end of each treatment week. Please keep a copy of your invoice for your records. You may choose to have us charge your credit card automatically at the end of each week for which services are rendered by completing the authorization form below. Should you choose to discontinue the automatic credit card service, it is your responsibility to notify the business office in writing. At CEPT, we work diligently to protect your privacy. Therefore, this document will remain in the business office and will not be accessible to your therapist. If you need to make changes, please contact the business office at 469-675-3153 (Allen), 281-769-1015 (Katy). Thank you in advance for your consideration. Name of Patient: __________________________________________________ I authorize CEPT to charge my credit card weekly for therapy services rendered. (A $40 fee will be charged for inactive/declined credit cards.) Please note: A copy of your credit card will be needed to have on file. Name of Cardholder as it appears on the card: ______________________________________________________

Card Type: MasterCard Visa Discover American Express

Credit Card #: (Please print clearly.)

Expiration Date: Security# (last 3 digits of card)

Cardholder’s Billing Address: ____________________________________________________________________

City______________________________________ State _______________________Zip Code________________

_____________________________________________________ _________________________________ Cardholder/Responsible Party’s Signature Date For Office Use Only: Date Business Office Received forms: _____________________Received by: ______________________________________



CLINIC POLICIES Please read and sign the following policies. Keep one copy of this document for your records and return a copy to the office to be kept in your patient file. Mission Statement “Therapy with a Purpose.” Cutting Edge Pediatric Therapy is dedicated to providing clients with the highest quality therapy services. Our Clinic is committed to helping our clients achieve their maximum level of function by providing comprehensive, community-based rehabilitation services which are an integral part of the total rehabilitation continuum. Treatment Sessions Half hour sessions of therapy are equal to twenty-five (25) minutes of therapy. Forty-five minute (45) sessions of therapy are equal to forty (40) minutes of therapy. One hour sessions of therapy are equal to fifty-five (55) minutes of therapy. The last 5-10 minutes of the sessions are dedicated to discussing the treatment session with the parent. ___________ (Initials) Payments and Billing Payment for service is due at the last session of each week when services are rendered. The individual who brings the patient to therapy is responsible for payment of the therapy session. Please make all checks payable to CUTTING EDGE PEDIATRIC THERAPY. An Automatic Credit Card Billing Agreement form must be completed in order to charge treatment sessions to your credit card. Copies of the credit card and the parent/guardian’s driver’s license must be on file with the completed Automatic Credit Card Billing Agreement. Please note, there will be a $40.00 charge for all returned checks and denied credit cards. The invoice provided at the time of service is your receipt. Statements and receipts are provided upon request only. ___________ (Initials) Scheduling/Participation In order for your child to reach his/her established goals in their treatment plan, it is imperative that your child attend his/her regularly scheduled visit. We at CEPT ask you to be mindful of this. We are aware that unanticipated emergencies (e.g. illness, family emergencies) take place. However, your child needs as much consistency as possible. We require our children to maintain a 75% attendance rate at their regularly scheduled time in order for them to continue to make progress. If appointments are not maintained on a consistent basis, we may have to move your child to a different treatment time. _______ (Initials) No Shows, Late Cancellations Our professional standard is to begin and end each session in a timely manner. Therefore, our expectation of our clients is that they will be punctual so that we are optimizing our appointments to the patient’s benefit. Appointments follow a specific treatment plan for each patient. As such, patient’s arriving more than 10 minutes late may be rescheduled and charged a late cancellation fee. Patients arriving more than 15 minutes late are considered No Shows unless other arrangements have been made. Certainly we understand that there are exceptions to this policy, such as sick children and family emergencies, which are not possible to control. We simply ask that you be as mindful as possible of your therapist’s schedule. Please note that it is your responsibility to contact the therapist that works with your child as soon as possible in order to eliminate any extra fees. You may also contact the business office at the number above and leave a message after hours, or email the office directly at [email protected] (Allen), [email protected] (Katy). ___________ (Initials)


No Shows: Appointments that are not cancelled are considered a No Show. Patients arriving more than 15 minutes late for their scheduled appointment are considered No Shows. No Show appointments are charged the full rate of the scheduled therapy session. ___________ (Initials) Late Cancellations: We request 24 hours notice for a cancelled appointment in order for our therapists to have the opportunity to adjust their schedule accordingly. An appointment that is not cancelled at least 2 hours prior to the scheduled appointment time is considered a late cancellation and clients will be charged a fee that equals half of the scheduled therapy session. ___________ (Initials)

Late Patient Pick-Up: The late pick-up fee is $36.00 for every 15 minutes. CEPT cannot accommodate children that are left unattended as our therapists must go on to the next scheduled appointment. If you leave the clinic during the patient’s session, please return five minutes prior to the conclusion of the session. We are mindful of those circumstances that are unavoidable. If an emergency occurs, please contact the business office as soon as possible so that the CEPT staff can make accommodations for the patient. ___________ (Initials)

Saturday Appointments These appointments are very limited and very desirable among our patients. Please understand this if you are choosing to commit to a permanent Saturday spot. Patients are only allowed to miss three Saturday appointments per year due to illness, vacation, etc. If more than three days have been missed in a short period of time, you will be asked to find a different appointment spot during the week. This is a medically-based clinic, so we ask that you be mindful of this when scheduling your appointment. ___________ (Initials)

Feeding Policy Patients who are involved in feeding appointments: Parents will be responsible for providing the correct food items that the therapist suggests for the patients. Therapists will not be responsible for providing food. If therapists do provide food, CEPT will charge a $25.00 monthly fee to cover expenses. ___________ (Initials)

Clinic and Waiting Room Manners The care and safety of children and/or siblings that accompany you to the patient’s session are your responsibility. In addition, a patient’s safety is the responsibility of the parent or guardian when not accompanied by a therapist. For their protection, children are not allowed in other areas of the building and are not permitted outside of the building unless escorted by a parent or guardian. Children in the waiting room are the responsibility of the parent or guardian. We ask that you please monitor your child in the waiting room and respect the property of CEPT and the other families in the reception area. We make every effort to keep our waiting room clean and tidy. If you bring snacks and/or drinks into the waiting room, please keep the area clean of any spills. We greatly appreciate the use of lidded cups. Please supervise your children in the restroom. Due to HIPAA regulations, we are not allowed to invite parents or guardians or siblings into the treatment area unaccompanied by a therapist and/or if another patient is being treated in the same area.

Thank you in advance for your courtesy. ___________ (Initials)

Authorization for Emergency Care This form is designed to meet the legal requirements established in HB 1452, Acts of the 61st Legislature, Regular Session, which provides that any person who has custody of a minor may give consent to medical care if the person has a signed affidavit by one or both parents authorizing the person to give consent. In order the meet all legal requirements; I hereby authorize representatives of CUTTING EDGE PEDIATRIC THERAPY to give consent for any necessary medical care for my child/children in said individual’s custody. ___________ (Initials)

Patient Release for Interns and Volunteer Staff

CEPT is a teaching clinic so on occasion student interns from various colleges may accompany your child’s therapist, observe treatments, and have sight of their notes. A background check through each respective institution is conducted for each student intern. CEPT periodically allows volunteers to assist in the clinic. They will be in the gym with your child under the supervision of your child’s therapist. Each volunteer has HIPAA privacy instructions. Volunteers are in place to learn and assist the therapist in the treatment of the patient and work for the benefit of patient’s care. Volunteers are not employees of CEPT and cannot assist you with billing, scheduling, medical or insurance information. By signing, I understand that my child’s treatment, testing, evaluations, daily notes and/or invoices will be seen by student interns in training to become Occupational Therapists and by volunteer staff. I understand that the student interns and/or volunteers will be involved in the treatment of my child. ___________ (Initials)

Photo/Video/Website/Print Consent I authorize CEPT to use my child’s photo(s) in our brochures, printed materials, and in the clinic, and my child’s photo(s) and/or video(s) on our website for the use of public relations, promoting various CEPT occupational therapy programs. I understand that I will be notified before the use of the photo(s) and/or video(s). _______ YES (Initials) _______ NO (Initials)

Therapy Dog Consent I authorize CEPT to use a therapy dog in therapy sessions as part of my child’s treatment. I understand that my child will never be left alone with the therapy dog. _______ YES (Initials) _______ NO (Initials)

Financial Agreement Insurance Policy: Cutting Edge Pediatric Therapy (CEPT) is an in-network provider with Blue Cross Blue Shield (BCBS) and files out-of-network insurance claims with United Healthcare (UHC), Aetna, Cigna, and Humana Insurance companies. Please notify us if your insurance company is not listed and we will research our ability to file your claims and provide treatment under your insurance plan.

Patients are billed for their annual out-of-network and in-network deductible at the beginning of their plan’s calendar year. After the patient’s out-of-network deductible has been satisfied, the patient is responsible for the co-pay amount set by their insurance carrier. Patients are billed for the remaining balance after payment has been received from their insurance company. Any non-covered services are the financial responsibility of the patient. In the event that payment for a performed service is denied by the insurance carrier, it is the patient’s responsibility to pursue action with their insurance carrier, as the policy is a legal contract between the patient and the insurance company. ___________ (Initials) Traditional Medicaid: Medicaid participants are exempt from our insurance policy. If your child does receive additional services, please notify us immediately. The requirements in order to be accepted and maintained will be mandatory attendance and cancellations with at least 24 hour notice. Any no shows will result in a warning. An additional no show will result in the discontinuation of the services. All sessions must be scheduled for a makeup within the same week to avoid denials from Medicaid. We are required to report your failure to make scheduled appointments to Texas Medicaid, which could result in a loss of benefits. _______ (Initials) For other carriers, there is no insurance coverage: If a patient has insurance carriers other than BCBS, UHC, Cigna or Aetna or has no insurance coverage, they are responsible for all charges incurred at the time of service. Co-payments, co-insurance, non-covered services and/or deductibles are the responsibility of the patient and are payable at the time of service. ___________ (Initials) Visit Limits: Visit limits are set by your insurance carrier. If your insurance policy has visit caps or limited visits, it is your

responsibility to track these visits as they occur. If you have participated in any therapy services with another provider during the insurance year, then you will need to include those visits. CEPT will do our best to keep track of these visits, but it is the parent’s responsibility to manage the visits overall. This is especially important if the child is receiving additional services such as speech therapy, physical therapy, chiropractic care, etc. _______ (Initials)

Joint Custody Payment Policy CEPT cannot divide credit card payments for children of divorced parents. CEPT’s policy requires that the parent or guardian who brings the child in for services be financially responsible for payment of treatment services unless other arrangements are made in advance through the business office. Parents may pay separately by check but payment must be made in full. For credit card payments, only the signatures of the cardholders present at the appointment are allowed. There are no exceptions to this policy. ___________ (Initials) BY SIGNING THIS DOCUMENT, I UNDERSTAND THAT PAYMENT IS EXPECTED AT THE TIME OF SERVICE. I MUST PROVIDE A PHOTO COPY OF MY INSURANCE CARD ANNUALLY AND ANY TIME THAT I CHANGE INSURANCE PLANS. IT IS MY RESPONSIBILITY TO NOTIFY CEPT OF ANY CHANGES. I UNDERSTAND THAT I MAY BE RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY MY HEALTH PLAN WITHOUT LIMITATION OF THE OUT-OF-NETWORK DEDUCTIBLE, CO-PAYMENT AND/OR COINSURANCE AMOUNT. ___________ (Initials) Your signature below validates your initials on each of the clinic policies described above. We appreciate your time and effort in completing these forms. Accurate patient documentation is necessary for CEPT to protect our patients’ rights. 800 N. Watters Rd., Ste. 150 21703 Kingsland Blvd., Ste. 100 Allen, TX 75013 Katy, TX 77450

Tel: (469) 675-3153 Fax: (469) 675-3154 Tel: (281) 769-1015 Fax: (281) 717-8947 Email: [email protected] Email: [email protected] ____________________________________________ ____________________________________________

Patient Name Parent/Guardian’s Name ____________________________________________ ____________________________________________ Patient’s Signature (if over 18 years of age) Parent/Guardian’s Signature ____________________________________________ ____________________________________________

Date Dat


AUTHORIZATION TO TRANSFER MEDICAL RECORDS

Patient Name: _______________________________________ Patient ID #: ______________________ Date of Birth: ___________________ Gender: ___________ Social Security #: _____________________ Name of Therapist: ______________________________ Clinic Location: __________________________ *I hereby authorize Cutting Edge Pediatric Therapy to release, disclose, and deliver the following information to:

Name of Practice: ___________________________________ Provider: __________________________ Address: _____________________________________________________________________________ City ______________________________ State: ________________________ Zip Code: _____________ Information Requested: I authorize the release of medical information to the patient above, including but not limited to the categories protected by state or federal law: a) patient treatment notes, b) patient testing and subsequent written evaluation reports, c) patient demographics. Redisclosure: This release does not authorize redisclosure of medical information beyond the limits of this consent. The recipient of this information is prohibited from using the information for other than the stated purpose, and from disclosing it to any other party. A general authorization for the release of medical or other information is not sufficient for this purpose. I understand and agree that the redisclosure requirement will apply to these records. Federal regulations state that any person who violates any provision of this law shall be fined not more than $500, in the case of each subsequent offense. Validity: I understand that this release will automatically expire one year from the date of my signature, and that I may revoke this release by sending a written notice to the person or entity authorized to make the disclosure. I agree that any release that has been made prior to revocation and that was made in reliance upon this authorization shall not constitute a breach of my rights to confidentiality. Facsimile Transmission of Records: The records may be faxed to the authorized recipient. I authorize the release of information as indicated above. Partial Medical Record for this Patient: Please specify party to be released _______________________ ______________________________________ _______________________________________ Signature of Patient Date (Or if under 18: Parent, Legal Guardian, Legal Representative) ______________________________________ _______________________________________ Printed Name DL# State Issued ______________________________________ _______________________________________ Witness Date Release By: _______________________________________ Date Released: _______________________


“therapy with a purpose” · activity training (adl), ot intensive programs, oral motor/feeding...

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