Physical Therapy Client Intake Form

Physical Therapy Client Intake Form
Date

MonthDayYear
Date
Client Name*

First NameLast Name
Gender:
Age:
Client Date of Birth:
Preferred location for services (New - Elmwood location is 524 Elmwood Park Blvd or Metairie Location is 3329 Metairie Road)*
What is your availability for the evaluation and/or weekly sessions?*
Will your child be attending any of TLC's Day Programs?*

Building BlocksConnect Kidsnone
How did you hear about TLC?*
Parent Name*

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:*

Area CodePhone Number
Home Phone number:

Area CodePhone Number
Email:*

Confirmation Emailexample@example.com
Referred to our clinic by?
Child's primary care physician:*
Phone Number:

Area CodePhone Number
Emergency contact:*

First NameLast Name
Phone Number:

Area CodePhone Number
Relationship with Client:
Email:*
example@example.com
Diagnosis (Please indicate any medical diagnosis or medical condition below):*
Reason for visit today and personal goals/main concerns you'd like to see improvement:*

Guarantor Information
Guarantor:

First NameLast Name
Date of birth:

MonthDayYear
Date
Relationship with client:
Social security number (optional):
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer:
Insurance Information
Name of Insured:

First NameLast Name
Date of birth:

MonthDayYear
Date
Social Security Number (optional):
Employer:
Health Insurance (We are not in network with Medicaid.)
Policy/Member ID#:
Group#:
Provider Service#:

Area CodePhone Number
Please upload a copy of the front and back of your insurance card.

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Insurance Card Cancelof
Please upload a copy of your driver's license.

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Driver's License Cancelof
Please upload a copy of the doctor's prescription for Physical Therapy.

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Driver's License Cancelof

Medical information
Does your child have any allergies? Please list:
Please describe illnesses, medical complications, or hospitalizations that your child has had and when:
Surgeries, if yes, please explain:
Any other helpful information about your child that is important for us to know:

Consent and Policies
I give permission for photographs/videos of my child for the purposes of treatment, education and documentation*
I give permission for photographs/vidoes of my child to be used for advertising, brochures and/or webspace. *
I have a prescription from my child's physician to authorize an initial evaluation for services.*
I have checked with my insurance company prior to this therapy visit and assert that I have obtained the necessary information regarding limits of coverage, co-pays and co-insurance.*
I hereby give Therapeutic Learning Center, LLC permission to evaluate and treat my child, and understand there will be written, oral, and electronic communication between care providers/physicians, insurance companies. Certification or licensing and quality assurance may review my child's records. I understand that all practices of confidentiality will be followed within use of the information gathered.*
I give Therapeutic learning Center, LLC permission to submit bills directly to the insurance carrier.*
Permission Slip, Indemnification, Medical Agreement and Grant of Rights

I hereby confirm that I am allowing my child to participate in the Therapeutic Learning Center, LLC’s (“TLC”) Clinic ("clinic"). I understand that the clinic is completely voluntary. My signature below is an acknowledgement of voluntary consent to allow my child to participate in this clinic. I agree to indemnify and hold harmless TLC Group from and against any and all claims, demands, expenses, losses and liability arising out of personal injuries or death to any person or the damage, loss or destruction of any property which may occur or in any way grow out of any act or omission by my child or any and all costs, expenses and/or attorney fees incurred as a result of any claims, demands, and/or causes of action, through, or under my child which may arise as a result of his or her participation in the clinic.

If any emergency medical procedures or treatments are required during the clinic, I hereby consent to the staff of TLC’s clinic, arranging for, or consenting to the procedures or treatment in his, her, or their discretion. The only time a decision will be made in regard to serious illness or accident will be when extenuating circumstances prevent direct contact with parents/guardians regarding the matter.

By signing a copy of this agreement, I hereby acknowledge and agree to the above terms, including the PERMISSION SLIP, INDEMNIFICATION, MEDICAL AGREEMENT and GRANT OF RIGHTS. I have reviewed and read this agreement. The terms and conditions were explained to me in full, and I understand its terms and conditions. I have been given ample opportunity to review this agreement with an attorney of my choosing. My signature below is voluntary. I further certify that I am of full legal capacity to execute this authorization.

The Undersigned expressly agrees that the foregoing Release, and Indemnity Agreement is intended to be as broad and inclusive as is permitted by the laws of the State of Louisiana and that if any portion or portions thereof shall be held invalid, it is agreed that said portion shall be severed from this Agreement and the balance shall, notwithstanding, continue in full legal force and effect.
I have read and agree to follow Therapeutic Learning Center, LLC Permission slip, Indemnification, Medical Agreement and Grant of rights.*
Signature*

Clear
Date*

MonthDayYear
Date
Payment and Attendance Policy:

Please read all parts carefully.
-I understand that I will be charged a LATE CANCELLATION/NO-SHOW fee of $75 if I fail to give at least 24- hour notice prior to canceling my appointment. If a make-up session is scheduled within the same week, this fee will not apply. - I understand that a "consult fee" of $20 per 15 min will apply if my child's therapist is asked to participate in a phone call or conference for more than 20 minutes.*
- I understand that TLC is only in network with BCBS, United Healthcare, and Aetna private insurance plans. TLC is in network with the following BCBS plans: HMO Louisiana HMO/POS, OGB MagLocal Plus - PrefCare, OGB MagOpenAccess - PrefCare, OGB Pelican HRA/HSA PrefCare, OGB Preferred Care, Preferred Care PPO. TLC is OUT OF NETWORK with the following plans: Medicaid, Abbeville General, Blue Connect HMO/POS, Community Blue HMO/POS, OchPlus, OGB MagLocal – BlueConn, OGB MagLocal BR - CommBlue, Precision Blue HMO/POS, Signature Blue HMO/POS, TQHN - By initialing below, I understand that if I do not have one of the plans listed above, my child will be charged private rates for services as follows: (evaluation $250, 60 min session $125, 45 min session $100, 30 min session $68). - I understand that I am responsible for knowing my co-payment amount and deductible amount and if my plan is "in network". I understand that if insurance information is not available or you do not have insurance, PAYMENT IS DUE IN FULL (see above prices) unless other arrangements have been approved by the administration. - As a courtesy to our clients, we will verify and file your insurance; however, THIS IS NOT A GUARANTEE OF COVERAGE OR PAYMENT. We strongly suggest that you read your policy manual as it pertains to therapy coverage. Many insurance companies have stipulations, such as usually & customary fees (UCR), limited therapy sessions, limited reimbursable amounts per session, deductibles, co-payments, supplies, etc. Such stipulations should be indicated in your policy manual. YOU ARE RESPONSIBLE FOR AMOUNTS NOT COVERED by your insurance. *
- I understand that "Fusion" will email me an invoice as frequently as insurance claims are approved and that TLC has no control over the approval period. Services can be paid electronically via the invoice emailed to you. Due to our HIPAA compliant platform, the invoice is only available for 7 days. - I understand that my child’s weekly appointment time will not be guaranteed if payments are not received for services within 7 days of the date of invoice. This applies to children seen at the clinic and at school. - I understand that Therapeutic Learning Center has the right to discharge my child if payment for service is not received within the month of services provided. Payment for services is expected following each session or at the time of service. - I understand that if payments are received past 30 days from the date of invoice, a $10 late fee will apply. If payments are received 45 days or more from the date of service, a $20 fee will apply. Any balance 60 days or more will be turned over to an OUTSIDE COLLECTIONS SERVICE. - If collections services or an attorney is employed to collect payments due, I will also be responsible for interest and expenses, including but not limited to costs and attorneys’ fees.*
- I understand that I will be charged a $20 out of office fee if my child is seen OUTSIDE OF THE THERAPY CLINIC SUCH AS A SCHOOL OR DAYCARE. - I understand that it is my responsibility to notify my child’s therapist or the front office if my child is not at school or daycare for the day the therapist is scheduled to see my child. - A no-show fee of $50 will be charged if your child is not at school or daycare and the therapist was not notified. - I understand that I will provide the office with a credit card to keep on file for payment when my child is seen outside of the therapy clinic such as school or daycare.*
- I understand that TLC has an attendance policy of 75% meaning my child will be present for at least 3/4 sessions or attend virtually whenever unable to come to the clinic to maintain this attendance rate. If my child's attendance falls below 75%, your child may be placed on the "stand by list" contacted when we have cancellations only. - I understand that if I miss 2 consecutive appointments without notice that my child will be removed from the therapy schedule. - I understand that TLC requires a current annual doctor's referral for OT services to take place. *
I have read and agree to follow Therapeutic Learning Center, LLC office payment and attendance policies.*
Signature

Clear
Divorced/Separated Parents and Custodial Arrangements

Therapeutic Learning Center, LLC does not get involved in disputes between divorced, separated, or custodial parenting arrangements regarding financial responsibility for their child's medical expenses. By signing as guarantor below, you agree to be financially responsible for the care we provide to your child, regardless of whether a divorce decree, custodial or other arrangement places that obligation on your former spouse or the child’s other parent. We will be happy to provide receipts for paid medical bills for you as requested.

FINANCIAL AGREEMENT AND GUARANTEE:

I accept full and complete financial responsibility for all medical and/or therapeutic services rendered to the registered patient(s) and agree to any and all insurance co-payments, deductibles, and co-insurance that may be required under the terms of my medical insurance policies, as well as pay for any medical care that is considered a “non-covered” service under the terms of my medical insurance plan.
Child's name:*

First NameLast Name
Guarantor's name:*

First NameLast Name
Guarantor's signature:*

Clear
Date*

MonthDayYear
Date
Therapy Attendance/No-Show/Cancellation Policy

Please read this carefully.

12 Week Therapy Session Duration

As of January 1, 2019, Therapeutic Learning Center will be changing the way we provide our therapy sessions in regards to the duration of services. We will be providing therapy in 12 week intervals. At the end of 12 weeks, you will meet with your therapist to discuss your child’s progress, attendance (see below for the 75% attendance requirement), and together, determine whether continued services will benefit your child. Oftentimes, the therapist will discuss your child's progress with you during or after each session which will serve in place of the 12-week meeting to discuss their progress.

No-Show/Cancellation

We realize that emergencies and other scheduling conflicts arise and are sometimes unavoidable; however, advance notification allows us to fulfill other client’s scheduling needs and keeps the clinic operating at its most efficient level. Due to our one-on-one 30, 45 & 60-minute treatments, missed appointments are a significant inconvenience to your occupational therapist, the clinic, and other clients. For the benefit of our clients and to optimize our therapist’s time, advanced notice for cancellations is requested.

We reserve your child’s therapy appointment times on a one to one basis. As a clinic policy, we do not double-book our clients so that we may provide optimum treatment for all our clients. We require 24-hour notice for all cancellations as it allows us to place another client in your cancelled appointment period to receive needed treatment. If the appointment is not cancelled outside of 24-hours, your appointment will be considered a “no show” and a $75 no show fee will be reflected on your account. We require a 75% attendance rate to keep your weekly appointment time. If the appointment can be rescheduled within the week, the missed appointment will not count against your attendance rate. We will allow for one “pass/missed appt” if the appointment is not cancelled outside of the 24 hours if your child is sick and missing the appointment is unavoidable.

After missing two consecutive appointments without notice or if you fail to maintain the 75% attendance rate, we reserve the right to place your child on a “stand by list” and services will be placed on hold or discharged.
Thank you for providing our office and our clients with this courtesy. Signing below indicates you understand and agree to the terms of this policy.
Credit Card on File Policy

To streamline our billing process and ensure timely payments, our practice requires all clients to maintain a valid credit card on file. This will facilitate efficient payment collection for copayments, coinsurance, and deductibles, to reduce administrative costs and time associated with billing and collections, and to ensure consistent cash flow for the practice.

Policy Details:

All clients must provide a valid credit card to be securely stored in our electronic health record system. The credit card on file will be used to process payments for:
- Copayments due at the time of service
- Coinsurance amounts
- Deductible payments
- No-show fees or late cancellation charges
Clients will be notified via email before any charge is processed, detailing the amount and reason for the charge.

Receipts for all transactions will be provided electronically or in person upon request.
Clients are responsible for updating their credit card information if it changes or expires.
In the event of a declined transaction, clients will be contacted to provide updated payment information.
This policy applies to all clients, regardless of insurance coverage or frequency of visits.

Security Measures: All credit card information is encrypted and stored securely in compliance with PCI DSS standards. Our staff is trained in handling sensitive financial information with the utmost confidentiality.
Signature*

Clear
HIPAA Information and Consent Form

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care.
Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:
1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing
care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff . You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manger or the therapist.
6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
7. We agree to provide patients with access to their records in accordance with state and federal laws.
8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.
9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward. Signing below indicates you understand and agree to the terms of this HIPAA policy.
Signature*

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Date*

MonthDayYear
Date
Should be Empty:

Physical Therapy Client Intake Form

Guarantor Information

Insurance Information

History

Medical information

Consent and Policies

Payment and Attendance Policy: