Patient Information

Patient First Name

Patient Last Name

DOB

Gender

Address

Address 1

Address 2

City

State

Zip Code

How did you hear about us?

Parent/Legal Guardian

Please provide names and the best possible phone number(s) and email. Be sure to notify us immediately of any changes.

Parent/Legal Guardian 1

Email

Phone

Parent/Legal Guardian 2

Email

Phone

Caregiver Information

Please list anyone who may bring your child to therapy.

Name

Relationship

Phone

Name

Relationship

Phone

Emergency Information

Contact Name

Relationship

Phone

Pediatrician

Allergies

Insurance Information

Primary Insurance

Policy Number

Group Number

Services

Current School

Grade

Please describe past Speech Therapy or Occupational Therapy services received.

Prenatal History

Is patient a child?

Yes No

Developmental History

Please list any developmental delays.

Therapy Concerns

Client Type
Speech Therapy Occupational Therapy

Cancellation Policy

In an attempt to provide the best service possible, any schedule changes need to be discussed at the end of the session and/or with the front desk administrator. We understand occasional changes may be necessary due to illness, vacations, etc. All cancellations must be made 24 hours in advance. Cancellations for Sunday or Monday need to be made on the Friday preceding that. We often have patients waiting to be accommodated into cancellation slots, so timely notice is of essence.

If a therapy session is not canceled in a timely fashioned as outlined above, or if a session is missed with no notice at all, The Therapy Place will charge you a $50 no-show fee. Please note that insurances do not reimburse for no-show sessions; it is solely the responsibility of the parent or guardian.

Two consecutive no-shows will cause your child’s slot to be put on hold until the matter is resolved. If the issue is not resolved within five business days, your child will forfeit his preferred slot.

Weekends and late afternoon appointments are prime slots. If you miss two such slots (even with proper notice), we reserve the right to give away the slot.

Please complete the enclosed Credit Card Authorization Form for us to have on file. Your credit card will only be charged in the event that your child misses his/her session and we have not received 24-hour notice.

Sign by typing your name

permission_2

I am a parent or legal guardian of the patient.

Your electronic signature is the online equivalent of your ink-on-paper signature, and can be provided by typing your name where indicated. The electronic signature will signify your understanding, acceptance, and authorization of the conditions of this legal document. You must be 18 years of age to legally sign this online waiver. If you are under 18 years old have your parent or legal guardian sign the waiver.

Authorization for Credit Card Use

permission

This credit card can be used for my copay/deductible

Name on Card

Card Number

Card Type

Expiration Date

Amount to Charge: $50.00 (USD)

I authorize the Therapy Place to charge the $50 to the credit card provided in the event of a no-show or in the event of a cancellation without 24-hour notice. I agree to pay for this purchase in accordance with the cardholder agreement.

Sign by typing your name

permission_4

I am a parent or legal guardian of the patient.

Your electronic signature is the online equivalent of your ink-on-paper signature, and can be provided by typing your name where indicated. The electronic signature will signify your understanding, acceptance, and authorization of the conditions of this legal document. You must be 18 years of age to legally sign this online waiver. If you are under 18 years old have your parent or legal guardian sign the waiver.

Agreement to Provide Therapy Services

You Are Responsible For Payment
You or your guarantor is responsible for payment for services provided by us at the time the medical services are provided. You further agree that you will be responsible for payment for disclosed non-covered services.
You agree that if payment in full is not received from your insurance carrier or from your personal
funds, and if a lawsuit or action is brought to collect this account or any portion of it, that you
agree to pay the costs of collection, including but not limited to, taxable and nontaxable costs and
disbursements provided by statute as well as attorneys’ fees amounting to one-third of the total
outstanding balance.

Health Insurance
If payment for the services that we provide for you may be covered by insurance, we will provide you with a copy of your bill at each visit which contains all the information necessary for you to bill your insurance carrier. We are required by law to submit the bill to your insurance carrier if the service provided is a covered service under your insurance plan. If we do this, it is still your responsibility to pay for any and all medical services provided to you and to request payment from your insurance carrier. If we have given you an estimate on the payment that your insurance carrier will pay, please understand that this is only an estimate and not a guarantee of payment by your insurance carrier. When an insurance carrier gives us “authorization” it is only a determination by
the insurance carrier that your policy provides coverage in general for the services that are to be
provided. There may be additional reasons why your insurance carrier will not, ultimately, pay for the services that are provided. You agree that regardless of what your insurance carrier ultimately pays, you are responsible for payment for the services.

Minors
If you are under the age of 18 at the time services are provided, your parent’s or legal guardian’s signature below constitutes an agreement and guarantee by your parent or legal guardian that they and you are responsible for paying for any and all fees. Your parent’s or legal guardian’s signature also is an acknowledgment that the services provided are “necessary” expenses.

Returned Checks
Returned checks are subject to a $25.00 returned check fee.

Authorization for Treatment
I hereby consent to and authorize The Therapy Place, PC, to perform occupational therapy treatment,
under the direction and supervision of a licensed occupational therapist, necessary for the above
named patient that The Therapy Place, PC or the patient’s physician advises to be necessary.
I understand and am informed that, as in the practice of medicine, there may be some risks associated
with the provision of occupational therapy. I understand that I have the right to ask about those
risks and to have any questions about my child’s condition answered prior to treatment.
I acknowledge and agree that either a parent or legal guardian will be present during each
treatment session.

I have carefully read and I fully understand this Informed Consent Form. I furthermore had the
opportunity to discuss this Form with the treating occupational therapist.

I understand that patients’ protected health information may be used and disclosed for treatment,
payment, or healthcare operations purposes. For a more complete description of the potential
uses and disclosures of protected health information, please refer to the Notice of Privacy Practices
issued on the first day of treatment. You have the right to review the Notice prior to signing this
Consent Form. To obtain additional copies of the Notice, please contact our office at 732-813-4263
I acknowledge that I have read agree to all of the information stated above.

Sign by typing your name

permission_5

I am a parent or legal guardian of the patient.

Your electronic signature is the online equivalent of your ink-on-paper signature, and can be provided by typing your name where indicated. The electronic signature will signify your understanding, acceptance, and authorization of the conditions of this legal document. You must be 18 years of age to legally sign this online waiver. If you are under 18 years old have your parent or legal guardian sign the waiver.

Assignment and Release

I understand that I am financially responsible for all services rendered whether or not paid for by insurance. If a referral form is required by my insurance company for a service and I neglect to secure it, I am financially responsible for the service provided. I hereby authorize the release of medical information deemed necessary by The Therapy Place, PC.

Sign by typing your name

permission_6

I am a parent or legal guardian of the patient.

Your electronic signature is the online equivalent of your ink-on-paper signature, and can be provided by typing your name where indicated. The electronic signature will signify your understanding, acceptance, and authorization of the conditions of this legal document. You must be 18 years of age to legally sign this online waiver. If you are under 18 years old have your parent or legal guardian sign the waiver.

Authorization for Sharing Protected Health Information

I authorize The Therapy Place to communicate with my child's school regarding my child's therapy.

I authorize the following:

Release Of Occupational/speech Therapy Records

Verbal And Written Communication With Teachers And Staff

I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective when The Therapy Place has already relied on the authorization for the use or disclosure of my health information or if my authorization was obtained as a condition of my obtaining insurance coverage and the insurer has a legal right to contest a claim.

Sign by typing your name

permission

I am a parent or legal guardian of the patient.

Your electronic signature is the online equivalent of your ink-on-paper signature, and can be provided by typing your name where indicated. The electronic signature will signify your understanding, acceptance, and authorization of the conditions of this legal document. You must be 18 years of age to legally sign this online waiver. If you are under 18 years old have your parent or legal guardian sign the waiver.

Authorization for Release of Medical Information

I authorize the release of any medical information necessary to process my claims. This authorization remains valid until I give written notice that it is explicitly revoked.

Sign by typing your name

permission_8

I am a parent or legal guardian of the patient.

Your electronic signature is the online equivalent of your ink-on-paper signature, and can be provided by typing your name where indicated. The electronic signature will signify your understanding, acceptance, and authorization of the conditions of this legal document. You must be 18 years of age to legally sign this online waiver. If you are under 18 years old have your parent or legal guardian sign the waiver.

Students

I allow students to observe my child's therapist during treatment.

Sign by typing your name

parent

I am a parent or legal guardian of the patient.

Your electronic signature is the online equivalent of your ink-on-paper signature, and can be provided by typing your name where indicated. The electronic signature will signify your understanding, acceptance, and authorization of the conditions of this legal document. You must be 18 years of age to legally sign this online waiver. If you are under 18 years old have your parent or legal guardian sign the waiver.

Communication/Appointment Reminder

I hereby authorize The Therapy Place to send me appointment reminders as well as other communications via e-mail or text message using the following information. Email reminders may contain patient or clinic information such as, but not limited to, patient first name and clinic location.

Type to sign your name

permission_10

I am a parent or legal guardian of the patient.

Your electronic signature is the online equivalent of your ink-on-paper signature, and can be provided by typing your name where indicated. The electronic signature will signify your understanding, acceptance, and authorization of the conditions of this legal document. You must be 18 years of age to legally sign this online waiver. If you are under 18 years old have your parent or legal guardian sign the waiver.