Logo
Street
City
State
Zip

Insurance Information - Attach a photo of the front and back of the insurance card.

Front:
Back:
PHOTO PERMISSION
Initial
Initial
Notice of Privacy Practices (HIPPA Acknowledgement/Consent)

I hereby acknowledge receipt of the Notice of Privacy Practices for ABC Pediatric Therapy, LLC. I hereby consent to the use and disclosure of my child’s protected health information (PHI) for the purpose of evaluation, treatment, payment, and health care coordination.

Thank you for your time in filling out this information regarding your child.

Attach a photo of your driver's license:

ABC Pediatric Therapy, LLC.
NOTICE OF PRIVACY PRACTICES

This Notice of Privacy Practices is given to you as a requirement of the Health Insurance Portability and Accountability Act (HIPPA). This notice communicates to you how we may use or disclose your protected health information (PHI), with whom we may share the information with, and about the safeguards we have in place to protect it. It also explains your rights to access and amend your protected health information. You have the right to approve or refuse the release of specific information outside of our practice except when the release is required or authorized by law or regulation.

Our policy has always been to keep the patient’s records safe. Records are usually kept in a folder of papers with the patient’s name and identification number on it. Records can also be stored in a computer or secured data software. Records tell what treatments and tests a patient has had and medical information the doctors have provided. Files are kept for at least 6 years from the date of termination of services.

ACKNOWLEDGMENT OF RECEIPT OF THIS NOTICE: You will be asked to provide a signed acknowledgment of receipt of this notice on the patient form. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. The delivery of therapy services will in no way be conditioned upon our signed acknowledgment. If you decline to provide a signed acknowledgment, we will continue to provide your treatment, and will use and disclose your protected health information for treatment, payment and health care operations when necessary.

OUR DUTIES TO YOU REGARDING PROTECTED HEALTH INFORMATION: “Protected health information” (PHI) is individually identifiable health information. This information includes demographics (for example, age, address), and relates to your past, present, or future physical or mental health or condition and related health care services. Our practice is required by law to do the following: • Keep your PHI private • Give you this notice of our legal duties and privacy practices related to the use and disclosure of PHI • Follow the terms of the notice currently in effect • Communicate to you any changes we may make in the notice.

HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION: Following are examples of permitted uses and disclosures of your PHI. These examples are not exhaustive.

1. Treatment- We will use and disclose your PHI to provide, coordinate, or manage your therapy and/or related services. This includes the coordination or management of your treatment with a third party. For example, we may disclose your PHI from time-to-time to another physician (for example, your ordering physician, orthopedic physician) who becomes involved in your care for diagnosis or treatment.

2. Payment- Your PHI will be used, as needed, to obtain payment for therapy services provided. This may include certain activities we may need to undertake before your health care insurer approves or pays for the therapy services recommended for you, such as determining eligibility or coverage for benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for speech or physical therapy might require that your relevant PHI to be disclosed to obtain approval of therapy

3. Practice Operations- We may use or disclose, as needed, your PHI to support our daily activities related to therapy services. These activities include, but are not limited to billing, collections, oversight or staff performance reviews, licensing, communications about a product or service, and conducting or arranging for other health care related activities. For example, we may disclose your PHI to a billing agency in order to prepare claims for reimbursement for the services we provide to you. We may disclose your PHI to school level students, that see patients in office for training/educational purposes. We may call you by name in the waiting room when your therapist is ready to see you. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment via phone, email, or mail. These business associates at our practice will also be required to protect your health information.

4. Required by Law- We may use or disclose your PHI if law or regulation requires the use or disclosure

5. Public Health- We may disclose your PHI to a public health authority that is permitted by law to collect or receive the information. For example, disclosure may be necessary to report child abuse or neglect •

6. Legal Proceedings- We may disclose PHI 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 process

USES AND DISCLOSURES OF PROTECTED 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 PHI. These circumstances will require you to give consent on our authorization for release of information form. Following are examples in which your agreement or objection is required. a member of your family that brings your child to therapy, a teacher or therapist and the child’s school, or a relative, a close friend, or any other person you identify that has involvement in your child’s therapy, or to someone who helps pay for the services provided.

YOUR RIGHT REGARDING YOU PROTECTED HEALTH INFORMATION: You may exercise the following rights by submitting a written request to our office manager.

Right to Request Restrictions- You may ask us not to use or disclose any part of your PHI for treatment, payment or health care operations. In your request, you must tell us (1) what information you want restricted; (2) whether you want to restrict our use or disclosure, or both; (3) to whom you want the restriction to apply; and (4) an expiration date. If we believe that the restriction is not in the best interest of either party, or that we cannot reasonably accommodate the request, we are not required to agree to your request. If the restriction is mutually agreed upon, we will not use or disclose your PHI in violation of that restriction. You may revoke a previously agreed upon restriction, at any time, in writing.

Right to Request Confidential Communications- You may request that we communicate with you using alternative means or at an alternative location not originally indicated on the initial patient forms. We will accommodate reasonable requests, when possible.

Right to Request Amendment- If you believe that the information, we have about you is incorrect or incomplete, you may request an amendment to your PHI as long as we maintain this information. Right to Obtain a Copy of this Notice -You may obtain a paper copy of this notice from us by requesting one or view it or download it electronically at our web site.

Complaints- If you believe these privacy rights have been violated, you may file a written complaint with our Office Manager. No retaliation will occur against you for filing a complaint.

You may request by written notice an accounting of the disclosures we have made of the patient’s PHI. The disclosure must have been made after April 14, 2003, and no more than 6 years prior to the date of request.

RIGHTS TO CHANGE TERMS OF THIS NOTICE

We reserve the right to modify and change the terms in this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. You may request and receive a copy of this Notice of Privacy Practices in writing or by accessing our web site at www.abcspeechtherapy.com.

ABC Pediatric Therapy, LLC
SUPPLEMENTAL INFORMED CONSENT FOR TREATMENT
  • I hereby acknowledge receipt of the COVID-19 Safety Guidelines for ABC Pediatric Therapy, LLC. I understand these Safety Guidelines, including new policies, procedures and protocols, are in addition to those already in place at the clinic.
  • I understand, agree and acknowledge that in order for a therapist at ABC Pediatric Therapy, LLC to engage with a child and provide a therapeutic environment, he or she may not be able to maintain a minimum 6’ distance from that child.
  • I understand, agree and acknowledge that in the course of receiving therapeutic services, a child may not tolerate wearing a face mask and/or tolerate a therapist wearing a face mask, and that either the child, therapist or both may have to remove their face masks in order to proceed with therapeutic services
  • I understand, agree and acknowledge that ABC Pediatric Therapy, LLC reserves the right to modify or change the COVID-19 Safety Guidelines. I also understand that a copy of any changes will be provided to me upon my written request
  • I understand, agree and acknowledge that all authorizations I have provided here will remain in effect until such time as ABC Pediatric Therapy, LLC is no longer providing treatment services to the child named herein.

Despite our careful attention to the guidelines stated above, there is still a chance that you could be exposed to an illness or COVID-19 in our clinic, just as you might be at other places in your community. By signing below, you accept the risk and consent to treatment

Parent’s/Guardian’s Signature: