Welcome to On Target Pediatric Therapy, LLC. We look forward to working with you and your child. Please fill out the following pages to the best of your ability. This paperwork will remain confidential. If you feel uncomfortable with a question below or are unsure how to answer it, please let us know prior to your initial treatment session.

Please bring the following items to your child’s first session: pediatrician's prescription for therapy, child’s insurance card and your ID

Some things to keep in mind for your first session/evaluation:

1. Please come prepared to let the therapist know what your goals for your child are. As the child’s parent, you see what his/her daily challenges are!
2. Bring socks. Our rule is no shoes in the therapy room!
3. Make sure your child is dressed in comfortable clothing that he/she can move in easily.
4. Don’t feed your child too much before the appointment. We’ll likely be doing swinging, spinning and lots of movement.
5. Please reschedule if your child is sick. We have a lot of children come into the clinic and while we do our best to clean the equipment, we wouldn’t want other children to catch any germs.
6. While we invite the parent/parents of children to join us in the therapy room for both the evaluation and treatment sessions, please refrain from bringing your child’s siblings into the therapy room. It can be quite distracting to both your child and the therapist and may present safety issues. During therapy sessions and the observation segment of the evaluation, we ask that you refrain from instructing or giving feedback to your child as we are using this time to observe what your child does independently.

Thank you so much for your understanding. We look forward to working with you and your child.

Please be aware that e-mail is not a completely secure method of communication.
I acknowledge that staff members have my permission to correspond via the above email address(es).
Name: First Name   Last Name   Relationship to Child:           Signature:   Signature   Date:   Date   

Referring Pediatrician      Name of Physician's practice      Phone Number                   
Please be aware that by signing below you are expressing your understanding that we can send any records to the physician on file.      

What age did your child reach the following milestones:
Rolling              Sitting               Walking             Talking       

Communication between our therapists and child’s teachers, other therapists and other professionals involved in your child’s care is often beneficial. If you sign below, you are allowing our therapists to communicate with child’s teachers, psychologists, case workers, other physicians or other members of your child’s team. Please add any comments below if you have any requests.
Signature   Signature   Date    Date     
Additional Comments:            

Health Insurance Company      
Member ID     
 Phone number      Phone Number   
Name of Primary Insured   First Name   Last Name
Social security number of Primary Insured      
Insured's date of birth   Date   
Insured's address (If different from above)   Street Address   Address Line 2   City   State   Zip 
Insured's Phone number   Area Code   Phone Number   
Employer        
Benefit's Phone Number (on back of card)      Phone Number  
Do you have secondary insurance? If yes, please provide information below:       

The notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPPA). It describes how we may use or disclose your child's protected health information, with whom that information may be shared, and the safeguards we have in place to protect it. This notice also describes your rights to access and or refuse the release of specific information outside of the system except when the release is required or authorized by law or regulation.
Acknowledgment of Receipt of this Notice
You will be asked to provide a signed acknowledgment of receipt of this notice. The intent is to make you aware of the possible uses and
disclosures of your child's protected health information and your privacy rights. The delivery of your child's health care services will in no way be
conditioned upon your signed acknowledgment.
Who will follow this Notice
This notice applies to all therapy services provided by On Target Pediatric Therapy LLC. It also applies to office and billing personnel.
Our responsibility regarding Protected Health Information
Your child's 'protected health information' is individually identifiable health information. This includes demographics such as age, address, email
address, and relates to your child's past present or future physical or mental health or condition and related health care services. We are
required by law to do the following:
● Make sure that your child's protected health information is kept private
● Give you this notice of our legal dues and privacy practices related to the use and disclosure of your child's protected health
information
● Follow the terms of the notice currently in effect
● Communicate any changes in the notice to you.
We reserve the right to change this notice. Its effective date is at the top of the first page and the boom of the last page. We reserve the right
to make the revised or changed notice effective for health information we already have about your child as well as any information received in
the future. You may obtain a Notice of Privacy Practices by calling the phone number at the top of this notice.
Our System
On Target Pediatric Therapy LLC works with several agencies and referral sources. Your child's health information will be shared in
the following manner:
1. Treatment - We will use or disclose your child's protected health information to provide, coordinate or manage your child's
health care and any related services. This includes disclosure to your physician or other health care providers who will
become involved in your child's care
2. Within our office for administrative activities, quality assessment, oversight and peer review.
3. With our billing personnel and as necessary to obtain payment for your health care services.
4. With your insurance company or other payers as required for payment.
5. With the referring agency and case manager, if applicable.
6. With any provider, school or agency with your written consent. You may request written or verbal information sharing in
writing. Your request should include a specified period of time for information sharing.
Required by Law
We may use or disclose your child's protected health information if law or regulation requires the use or disclosure. We will notify the
appropriate government authority if we believe the patient has been a victim of abuse, neglect or domestic violence.
Health Oversight
We may disclose protected health information to a health oversight agency for activities authorized by law such as audits,
investigations and inspections. These health oversight agencies may include government agencies that oversee the healthcare
system, government benefit programs, other government regulatory programs and civil rights laws.
Legal Proceedings
We may disclose protected health information 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 purposes.
Parental Access
We may disclose your child's protected health information to parents, guardians and person's acting in similar legal status.
Uses and Disclosure of Protect 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 child's protected
health information. Since this service may be provided in a natural environment, others present during a session such as family
members, friends or day care providers may hear health information regarding your child. Please notify your therapist if you do not
want your child's protected health information to be discussed.
Your rights regarding your Child's Health Information
You may exercise the following rights by submitting a written request to the On Target Pediatric Therapy office.
1. You may inspect and obtain a copy of your child's protected health information that is kept as a part of medical and billing
records.
2. You may ask us not to use or disclose any part of your child's health information for treatment, payment or health care
operations. Your request must be made in writing. This request will be honored if we mutually agree that the restriction will
not harm your child.
3. You may request that we communicate with you using alternate means. We will not ask the reason for your request and
will accommodate reasonable requests when possible.
4. If you believe that the information we have about your child is incorrect or incomplete you may request an amendment to
your child's protected health information as long as we are responsible for and maintain this information. While we will
accept your requests for amendment, we are not required to agree to the amendment.
5. You may requests that we provide you with an accounting of the disclosures we have made of your child's protected
health information. This right applies to disclosures made for purposes other than treatment, payment, or health care
operations as described in this Notice of Privacy Practices. This disclosure must have been made after September 1st,
2015, and no more than 6 years from the date of the request. This right excludes disclosures made to you or authorized
by you to family members or friends involved in your child's care, or for notification. The right to receive this information is
subject to additional exceptions, restrictions and limitations as described earlier in this notice
Federal Privacy Laws
This notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act
(HIPAA). There are several other privacy laws that also apply including the Freedom of Information Act and the Privacy Act. These
laws have been taken into consideration in developing policies and this notice of how we will use and disclose your child's protected
information.
Complaints
If you believe these privacy rights have been violated, you may file a written complaint with the Department of Health and human
Services. No retaliation will occur against you for filing a complaint.
This notice is effective in its entirety as of November 1st 2015.

Children requiring therapy benefit greatly from an alliance between the parents and therapist. Most therapy sessions include demonstrations of techniques for parents so they can follow through with observed and recommended activities. Your child requires your assistance in order to progress. If your regular child care provider will be accompanying the child to his/her therapy session, you may provide permission for that provider to be present during therapy sessions.

I  give      permission to attend therapy sessions with my child. The therapists at On Target Pediatric Therapy have my permission to provide any relevant medical information necessary to provide service and instruct him/her regarding home exercise programs
Signature   Signature   
Date   Date