New Patient History Questionnaire

New Patient History Questionnaire
Welcome to Summit Pediatric Therapy! On behalf of the entire team, we are very happy to have you join our pediatric therapy family. In order to get started, we need each new patient to complete our new patient paperwork. In an attempt to make the process as easy as possible, we allow our patients to complete their paperwork online.

Please complete the form below at your earliest convenience. Should you have any difficulty accessing or submitting our form, please don’t hesitate to call us at 720-542-8737.
Patient's Name*

First NameLast Name
Child's Age
Date of Birth*

MonthDayYear
Date
Gender Assigned at Birth*

FemaleMale
What pronouns does your child go by?*

she/her/hershe/him/histhey/them/theirs (singular)ze/hir/hirs
What are your primary concerns*

Speech TherapyOccupational TherapyPhysical TherapyPhysical Therapy (Birth-12 Months Old ONLY)Feeding Therapy
What are your biggest concerns?*
Please provide as much detail as possible. The more information the better!!!
Insurance Information
Insurance Carrier*
Subscriber's Name*

First NameLast Name
Subscriber's Date of Birth*

MonthDayYear
Date
Member ID*
Upload Copy of the Front and Back of Insurance Card

Browse Files
Save yourself time, upload your insurance card Cancelof
Does Your Child Actively Have Medicaid Coverage?*

YesNo
Has Your Child Ever Had Medicaid Coverage?*

YesNo
If Your Child Has or Had Medicaid Coverage, Please Provide the Coverage Time Frame
Family Information
Which Parents/Guardians are Involved in Child's Life?

Parent/Guardian 1Parent/Guardian 2Parent/Guardian - Other
Parent/Guardian's Name

First NameLast Name
Relationship to Child
Preferred Phone

Area CodePhone Number
Preferred Email
example@example.com
Parent/Guardian's Name

First NameLast Name
Relationship to Child
Preferred Phone

Area CodePhone Number
Preferred Email
example@example.com
Parent/Guardian's - Other

First NameLast Name
Relationship to Child
Preferred Phone

Area CodePhone Number
Preferred Email
example@example.com
Patient's Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Secondary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How many siblings does the patient have?

Sibling Information

	First Name	Last Name	Age
Sibling 1
Sibling 2
Sibling 3
Sibling 4

Is your child adopted?*

YesNo
If so, when and where?
Primary language spoken at home*
Secondary language*
Is there a family history of the following?*

No Family HistorySpeechArticulationLanguageVoiceStutteringLearning DisabilityOther
Has your child previously received therapy?*

YesNo

Previous Therapy

	From Age	To Age	Where
Speech Therapy
Occupational Therapy
Physical Therapy
Feeding Therapy
Behavioral Therapy

Primary Care Physician*
Name of Practice*
Phone

Area CodePhone Number
Has your child been seen by or is currently been seen by a specialist?

GIENTDentistOrthodontistOther

	Description
Diagnosis 1
Diagnosis 2
Diagnosis 3
Diagnosis 4
Diagnosis 5
Diagnosis 6
Diagnosis 7
Diagnosis 8
Diagnosis 9
Diagnosis 10

	Description
Allergy 1
Allergy 2
Allergy 3
Allergy 4
Allergy 5

Birth to 12 Months - Physical Therapy
At what age did your child? In Months
Ability to look left and right equally
Rolling to the side
Rolling tummy back
Tummy time tolerance
Sitting
Quadruped (hands & knees)
Crawling (army crawl with tummy on floor)
Creeping (hands & knees with tummy off floor)
Pulling to stand
Standing
Walking

Recap
Is there anything else about your child that is important for us to know?
Please attach relevant information (IEP, Recent Evaluations, Therapy Progress Notes, Audiograms/Hearing Results)

Browse Files

Cancelof
Appointment Reminder Consent

Complete this form and sign below to give your permission for Summit Pediatric Therapy to provide automatic appointment reminder service by email or by cell phone text message.
Select One Option

Summit may send email messages to confirm my child's appointmentSummit may send cell phone text messages to confirm my child's upcoming appointment
Email For Appt Reminders
example@example.com
Phone Number For Appt Reminders

Area CodePhone Number
Additional Patient Forms

All documents are available on Summit Pediatric Therapy's website.
HIPAA RELEASE & CONSENT

The Department of Health and Human Services has established a “Privacy Rule” to help ensure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for healthcare providers to obtain their patient’s consent for use and disclosure of health information about the patient to carry out treatment, payment, or healthcare operations.

As our patient we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your healthcare information and information about treatment, payment, or healthcare operations, in order to provide healthcare that is in your best interest.

We also want you to know that we support your full access to your personal medical records. We may have to disclose personal health information for purposes of treatment and/or payment.

I agree to discuss my child’s progress during the group held by Summit Pediatric Therapy along with the other participant’s families. Should I have any additional concerns or questions that I would like to discuss in private with my child’s therapist, I understand I can arrange a separate time to discuss the matter. You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent.

If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer. You have the right to review our privacy notice, request restrictions, and revoke consent in writing after you have reviewed our privacy notice.
TEXT MESSAGE COMMUNICATION

I consent to receive text message reminders and phone call reminders from Summit Pediatric Therapy. I understand that this consent to receive email reminders and text message reminders will apply to all future appointment reminders/feedback/practice notifications unless I request that to be changed. You may refuse consent to email or text message reminders at any time.
FINANCIAL POLICY

ALL PAYMENT IS EXPECTED AT THE TIME OF SERVICE.

You are responsible for ensuring all charges are paid whether by you or by your insurance carrier. You are responsible for providing us with current insurance at the time of service. Claims will only be submitted to the insurance carrier you provide at the time of service.

All patients are required to keep a valid credit card on file; expected copayment must be made at the time of service. Summit Pediatric Therapy accepts all major credit cards and debit cards including HSA/FSA cards.

Accounts with an outstanding balance will be charged to the credit card on file. If your credit card expires or is declined, you must make arrangements for payment to avoid a break in service, services being discharged, or having your account sent to collections.

INSURANCE:

Summit will bill participating insurance companies and we will try our best to collect from insurance as a benefit to you. It is your responsibility to provide us with up-to-date insurance information. You are expected to pay your portion at the time of service. If we have not received payment from your insurance company within 60-days of the date of service, you will receive a statement and the balance is your responsibility. If we have not received payment within 90-days, your credit card will be charged at our current private self-rates.

PRIVATE SELF-PAY:

If you are electing to be seen as a private self-pay patient, your insurance will not be billed for these sessions. You are expected to pay the private-pay rate at the time of service. Private-pay sessions will not be retroactively billed to insurance at a later date; you agree to pay for these services at your own expense.

If you need assistance or have questions, please contact our billing department Monday through Friday at 720-542-8737 or info@summitpedstherapy.com
ATTENDANCE POLICY

Regular attendance is important to achieve progress and success in therapy, and it is necessary that all appointments be kept whenever possible. Failure to keep your scheduled appointments at Summit Pediatric Therapy hinders our ability to provide the best care to our patients. Because of this, we must enforce the following attendance policy:

Attendance Rate Policy
Regular attendance is imperative to your child’s progress towards their therapy goals. Inconsistent attendance is one of the primary causes of limited progress. If attendance falls below 70% for scheduled appointments on a rolling 90-day period, we reserve the right to discharge services. If there are 2 consecutive no showed appointments, we reserve the right to discharge services.

Cancellation Policy
To ensure we can meet the needs of all clients, Summit Pediatric Therapy requires at least 24 hours' notice for cancellations. A $50 penalty will be charged for individual therapy sessions and $100 for evaluations, if adequate notice is not provided. This will be charged to the credit card on file.

Late Policy
Patients arriving 10 or more minutes late for their appointment will be rescheduled, and the session will count as a missed appointment subject to cancellation fees.

Illness
For the safety of our staff and other clients, please do not bring your child to therapy if they have had diarrhea, vomiting, or a fever within the past 24 hours.

Vacation Holds
Recurring therapy time slots may be held for vacation absences up to two weeks, provided at least one week's notice is given. To secure your time slot beyond this period, payment for the session in full is required.

Rescheduling Appointments
Frequent rescheduling of appointments may result in the loss of a recurring time slot. Families with such patterns may be placed on attendance watch, with the right to discontinue services at any time the policy is in violation.

Waiting Room: For the safety of our patients, we require all parents and caregivers to remain in our reception area or outside of the office in the immediate hallway at all times.
LIABILITY RELEASE

I, the parent/guardian of the child authorize my child to participate in therapies at Summit Pediatric Therapy. I acknowledge the risks and potential for risks of Occupational Therapy, Physical Therapy, and Speech Therapy. However, I feel that the possible benefits to myself / my son / my daughter / my ward are greater than the risks assumed. I hereby, intending to be legally bound, for myself, my heirs and assigns, executors or administrators, waive and release forever all claims for damages against Summit Pediatric Therapy, instructors, therapists, aides, volunteers, and/or employees for any and all personal injuries, physical or mental condition, known or unknown, to said person, and the treatment thereof, as a result of, or in any way growing out of the acts of Summit Pediatric Therapy, its agents, employees, representatives, successors or assigns, including but not limited to their negligence or gross negligence, in rendering the services above described or in any way incidental thereto.
CONSENT FOR EMERGENCY MEDICAL TREATMENT

In case of an emergency and/or if I am not present and cannot be contacted at the telephone numbers on my child’s parent information form, I understand that in the event of a medical emergency, Summit Pediatric Therapy will call 911 or other appropriate medical personnel. If an ambulance must transport my child, I understand that it will take my child to the closest medical facility available. I give permission to the personnel of Summit Pediatric Therapy to consent to any x-ray examination, anesthesia, medical or surgical treatment, and/or other emergency medical care advised by a licensed physician or dentist and rendered under the provisions of the Medical or Dental Practice Act. I understand that Summit Pediatric Therapy will not be liable for any first aid treatment, medical or hospital care, medications, or surgical procedures rendered pursuant to this consent.
Credit Card Information Form

Please fill out the form below to have your credit card information on file for billing purposes.
Name on card*

First NameLast Name
Credit Card Type*

VisaMastercardAmerican ExpressDiscoverOther
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Credit Card Number*
Expiration Date (MM/YY)*
CVV (3 or 4 digit code)*
Today's Date

MonthDayYear
Date
Name of person submitting this form

First NameLast Name
Phone number

Area CodePhone Number
Email address
example@example.com
Signature

Clear
Should be Empty:

	Name of Rx	Reason for Medication
Rx 1
Dx 2
Dx 3
Dx 4
Dx 5

New Patient History Questionnaire

Insurance Information

Family Information

Birth & Medical History

VERY IMPORTANT - PLEASE MAKE SURE ALL KNOWN MEDICAL DIAGNSOSIS ARE DOCUMENTED

Educational / Social Emotional

General Development

Speech-Language Development

Occupational/Physical Therapy

Birth to 12 Months - Physical Therapy

Feeding Therapy

Recap

Additional Patient Forms

Credit Card Information Form