Fill - Free fillable 12812 Old Glenn Highway Suite A-5 Eagle River, PDF form

PATIENT NAME: ____________________________________________

12812 Old Glenn Highway Suite A-5

Eagle River, AK 99577

Phone: (907) 317-5895

Fax: (866) 628-8601

Patient Intake/ Billing Information

Last Name: First Name: Middle Initial:

Sex: Patient DOB: / /

Parent or Guardian Name:___________________________________________________________

Address of child:

City: State: Zip: Phone:____________________

Mailing Address:

City: State: Zip:________

Email:

Do you text? Text number, if different than above: .

Responsible billing Party: _________________________________________________

Primary Insurance:________________________________ Insurance holders name:___________________________

Insured (i.e. parents) DOB:___________________________________________________________________________

Insurance identification number: ______________________________________

Secondary Insurance: _____________________________Insurance holder name:______________________________

Insured (i.e. parents) DOB:____________________________________________________________________________

Insurance identification number: ______________________________________

Emergency Contact:________________________________________Phone:

PATIENT NAME: ____________________________________________

Release, Assignment and Statement of Responsibility

I authorize release of any information necessary to process my insurance claims and assign and request payment directly to the provider(s).

I understand that I may revoke consent at anytime in writing to this office. I further understand that I am responsible for payment for all

products and services rendered to me or any patient for which I am the guarantor of payment.

Consent to Treatment

By signing below, I give my consent for examination and the performance of any tests or procedures needed. If the patient is a minor by

signing I give consent for examination, tests and procedures for the above minor patient.

_____________________________________________________________________________________________________________

Signature of Patient or Personal Representative: Date:

(Or Witness if signature is by mark)

Printed Name of Personal Representative or Witness Description of Personal Representative’s Authority:

Release of Liability

I as the undersigned acting as legal guardian and or legal power of attorney, give my informed consent for

child:________________________________, to participate in any Occupational Therapy activity that is

conducted in any location, this includes transportation to and from the location, on-site and community based

therapeutic activities. These activities may include but are not limited to sports, water, boats, bicycles, swings,

playgrounds, climbing walls, snow, ice, all wheeled recreational items, balls, ropes and jumping from various

heights, trees, and interaction with other children or persons. I am aware that there are inherent risks in

participating in activities that may challenge my child and I accept and am aware of these. In the event of any

physical or mental injuries sustained in any activities facilitated by Playful Learning Pediatric Therapy, LLC its

business associates in contract, all employees, managers and members of Playful Learning Pediatric Therapy,

LLC are released from any and all liability.

This release of liability is perpetual during the treatment time of the above

participating person- beginning date of signature below.

Child name: DOB:_____________________

Signature of Patient or Personal Representative: Date:

(Or Witness if signature is by mark)

PATIENT NAME: ____________________________________________

Printed Name of Personal Representative or Witness Description of Personal Representative’s Authority:

Mailing Address:

12110 Business Blvd Ste A06-413

Eagle River, AK 99577

Phone: (907) 317-9349

Fax: (866) 628-8601

Notice of Privacy Practices &

Your Rights

We are required by federal and state laws to maintain the privacy of your/ your child’s ‘Protected Health

Information’, PHI. Your signature below indicates you have received a copy of the ‘Notice of Privacy Practices

and Your Rights’, which describes how health care information about you or your child may be collected, used

and disclosed for purposes of treatment or payment or for other specified purposes that are permitted and

required by law. This notice also details how you may access this information.

If you have any questions regarding this notice, please call us at (907) 317-9349

Child name: DOB:_____________________

Signature/Title of Patient or Personal Representative: Date:

(Or Witness if signature is by mark)

Printed Name of Personal Representative or Witness Description of Personal Representative’s Authority:

Witness signature/Title: Date:

PATIENT NAME: ____________________________________________

12812 Old Glenn Highway Suite A-5

Eagle River, AK 99577

Phone: (907) 317-9349

Fax: (866) 628-8601

PATIENT AGREEMENT

Playful Learning Pediatric Therapy, LLC offers occupational therapy services for patients referred to our practice. We are a licensed

provider who develops individualized treatment plans to identify the services that will best suit your therapy needs. We work with

your primary care practitioner to coordinate your care.

Following your initial assessment visit(s), we develop a specific plan of care for review and approval by your referring provider. Once

your referring provider signs your Treatment Plan, we can begin working with you to improve your health condition. We are pleased

to serve your occupational therapy needs and encourage your feedback to alert us to anything we can do to provide you the highest

quality of care.

We require certain information from each patient in order to begin your care. The attached forms need to be completed in order for us

to get you started as our patient. Please do your best to complete all the information. If certain information does not apply to you,

please indicate that by noting “N/A” (“Not Applicable”) so that we know that you did not overlook anything.

Each healthcare insurance payer has different guidelines for allowing coverage of occupational therapy services. If your healthcare

insurance payer does not cover occupational therapy services, you are welcome to make self pay arrangements for the usual and

customary pricing of our services.

ALASKA MEDICAID RECIPIENTS:

Alaska Medicaid requires that a physician, physician assistant or advanced nurse

practitioner refer you to our practice before we can perform an initial assessment on

you. After we have completed your initial assessment, we develop an individualized

Treatment Plan to meet your specific therapy goals.

Your primary care practitioner will need to review & approve your Treatment Plan,

and then return it to our practice before we can begin your treatment. Please

understand that we cannot schedule your therapy appointments until after we have

received your approved Treatment Plan.

NO SHOW POLICY/ATTENDANCE POLICY

If you cannot make it to a scheduled appointment, please contact our office at least 12 hours in advance. We will remove the patient

from the schedule after 3 no-shows or 3 last minute cancelations (within 8 hours). Attendance is imperative in order for our therapists

to make progress on the patient’s plan of care. Please ensure 80% attendance for your appointments at all times. After an initial

warning regarding attendance, we will remove the patient from their time slot.

PATIENT NAME: ____________________________________________

WAIT LIST FOR SERVICES

If you would like to reschedule an appointment for a day or time that is not available, please let us know and we will place you on our

waiting list. If another patient cancels their appointment, we will contact patients on the waiting list on a first come, first call basis.

MEDICAID & PRIVATE INSURANCE

CO-PAYMENTS, DEDUCTIBLES AND NON-COVERED SERVICE

Additionally, Medicare and private healthcare insurance payers have deductible and co-payments for occupational therapy services that

are the responsibility of the patient.

PATIENT DISCOUNTS FOR IMMEDIATE PAYMENT

If you would like to pay for your services at the time of your visit, we can offer you a 10% discount.

COLLECTION OF PAST DUE ACCOUNTS

We communicate with our patients to resolve past due accounts in all cases. If we cannot reach a patient by phone following the return

of undeliverable mail, or if a patient payment agreement cannot be made or paid as agreed, we are forced to use the services of a

professional collection agency. Once an account is placed with a collection agency, we cannot take the account back. Please let us

know when or if your patient contact information changes so that we can always reach you, if needed, to discuss past due accounts.

FINANCIAL AGREEMENT

New patients approved for occupational therapy services are responsible for any and all charges not paid for by healthcare insurance

payers. By signing this patient agreement, you are acknowledging that you understand this condition of service and commit to promptly

paying Playful Learning Pediatric Therapy, LLC for the services we provide to you, our valued customer. We accept cash, personal

checks, and money orders. We also are willing to make reasonable payment arrangements to keep your account current.

PATIENT STATEMENT OF AGREEMENT

My signature below signifies that I have read and understand this patient agreement for Playful Learning Pediatric Therapy, LLC to

provide me occupational therapy services. I agree to the terms in this patient agreement and intend to comply with them to the best of

my ability. I understand that if I fail to follow the terms of this agreement, I could be discharged from service.

Signature of Patient or Personal Representative: Date:

(Or Witness if signature is by mark)

Printed Name of Personal Representative or Witness Description of Personal Representative’s Authority:

PATIENT NAME: ____________________________________________

12812 Old Glenn Highway Suite A-5

Eagle River, AK 99577

Phone: (907) 317-9349

Fax: (866) 628-8601

RELEASE OF PATIENT INFORMATION AUTHORIZATION FORM

PATIENT NAME:

DATE OF BIRTH:

PHYSICIAN/PEDIATRICIAN NAME:

CONTACT NUMBER:

PEOPLE & ENTITIES I AUTHORIZE TO RECEIVE MY PROTECTED HEALTH INFORMATION

NAME OF ENTITY

CONTACT INFORMATION

Please list medical practitioner(s), spouse, caregiver(s), guardian(s), etc. you are authorizing to receive PHI.

The purpose of this release of protected health information authorization:

I hereby authorize the use or disclosure of my health care and/or other information within my patient record to the entities stated above.

I understand that this authorization is voluntary. I understand that my records may contain sensitive information. I understand that I

may revoke this authorization at any time by signing the revocation section at the bottom of this form, or by notifying Playful Learning

Pediatric Therapy, LLC in writing, but if I do, it will not affect actions taken on this authorization before my revocation was received. I

understand that Playful Learning Pediatric Therapy, LLC will not condition my treatment, payment, or eligibility for services based on

whether I provide this authorization.

I understand that if the person(s) or entities I authorize to receive my protected health information are not a health plan or health care

provider, the released information may no longer be protected by federal privacy regulations. To the extent that this information is

required to remain confidential by federal or state law, the recipients of this information must continue to keep this information

confidential. I understand that I may request a copy of this signed authorization.

_____I hereby give permission to Playful Learning Pediatric Therapy, LLC to photograph, video or audio record therapy sessions.

These photos, videos or audio recordings can be used for education, marketing, or any other general purpose.

This authorization expires on the following date or event:

Signature of Patient or Personal Representative: Date

(Or Witness if signature is by mark)

Printed Name of Personal Representative or Witness Description of Personal Representative’s Authority:

PATIENT NAME: ____________________________________________

NOTE: This authorization was revoked on: _______________ (see attached revocation). Complete when/if revoked.

Date

A PHOTOCOPY OF THIS AUTHORIZATION IS AS VALID AS THE ORIGINAL

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