Was your pregnancy full term? Yes/No* If not, how many weeks? ex: 36*
Birth weight: blanks* How long was your hospital stay? blank*
Was alcohol consumed during pregnancy? Yes/No* If yes, how often? blank*
Can most adults understand your child? blanks* Can most children understand your child? blank*
Does your child become frustrated trying to talk? blanks*
Has anyone told you he/she is concerned about your child's speech and language? blanks* Are you concerned with your child's speech and language? blank*
Is there another language spoken in the home? blanks* If so, what language(s)? blank*.
I, blanks, hereby consent to the release of information and records regarding my son/daughter, blank, to the following agencies, including StoreySmith Pediatric Clinic, PA for the purpose(s) of: treatment, payment and regular professional operations:
Primary Care Physician: blanks Area Code Phone Number Public School: blank Area Code Phone Number Health Insurance Company: Name Child Development Services: Caseworker Name Other: Other
Non-Covered Services Waiver
Occupational/Speech/Physical Therapy Evaluation:
Billed between 4-6 hours - includes face-to-face time + the time it takes to write the formal evaluation.
Approximate Out of Pocket Cost: $500 - $800 total
Occupational/Speech/Physical Therapy Treatment Session:
Approximate Out of Pocket Cost: $150 - $250 per hour session
$125 - $200 per 35 minute session
$50 - $100 per half hour session
**PLEASE NOTE: Payment is due at the time of service unless otherwise specified by the front office staff.
Secondary Payment Source
-I am aware that I have been informed and I understand that these services may be excluded or excludable under my insurance policy and therefore all costs associated with these services may not be an allowable expense under my insurance. By signing this waiver, I hereby agree, in advance, in writing, to accept full finanical responsibility for all cost associated with the non-covered medical services performed by the named provider.
-I am aware that I am responsible to notift the provider of a change of insurance and/or policy as soon as the change is made. I am aware that a break in contract or a new insurance policy could interrupt my physician's referral and payment of services. I understand and agree, in advance, in writing, to accept full financial responsibility for all cost not paid due to an untimely notification of change in policy.
- I am aware that I am responsible for any services not covered by my insurance, due to my deductible, and for the co-pay and/or co-insurance required by my plan. I also understand services will be charged to the credit card listed below once EOB is received from my insurance unless my child has a secondary insurance.
I hereby authorize StoreySmith Pediatric Clinic, PA to charge the credit card on file for balances due on deductibles, copays and services. blanks*
I understand that I am required to make a payment at the time of service and I am responsible for all charges not covered by my insurance. blanks*
I have read and understand StoreySmith Pediatric Clinic, PA's cancellation policy. I also authorize the clinic to charge the credit card on file for any cancellation ($75.00) not made up within 2 weeks. blanks*
StoreySmith Pediatric Clinic (SSPC) allows clients and their parents/guardians the ability to communicate with providers via electrionic mail (email) for non-urgent matters if the arrangement is agreed to by both parties.
SSPC may forward emails as appropriate for diagnosis, treatment and other related reasons. As such, SSPC staff other than your clinician may have access to emails that you send. Such access will only be in order to provide service to you. Otherwise, SSPC will not forward your emails to independent third parties without your prior written consent, except as authorized or required by law.
If SSPC agrees to exchange email with you, you must agree to observe the following requirements:
Appropriate Purposes for Email:Email may be used to request information, including updates on the progress of treatment, and to ask non-urgent questions. It should not be used in emergencies. If you need an immediate response, please contact SSPC office by telephone.
Documentation: Substantive email communications will be documented by placing a copy of the message in the client's record.
Sending Emails: The subject of the email should include the purpose of the email.If a message is ever returned because of a "bad address", please make sure that you entered the complete address as it was given to you. If you are sure that you entered the address we gave to you, please call us to verify you have the correct address and that the email system is functioning properly. If we do not answer your email in two (2) business days, call us. SSPC may choose to stop email communication at any time.
Security and Privacy of Email: The clinicians and staff of SSPC must verify that the email address of any communication received from clients or their parents or guardians matches the email address provided client, parents or guardian. If the email addresses do not match, SSPC will not respond to the email. It is the responsibility of the client, parent or guardian to notify SSPC if the client, parent or guardian has changed his or her email address. Without this notification, the physician will not respond to client, parent or guardian inquiries.
Do not use email to send or request very sensitive information. SSPC cannot and does not guarantee the privacy or security of any messages being sent over the internet. There is the potential that email sent over the internet can be intercepted and read by others. Additionally, you should be aware of and understand that if you use email provided by your employer, any email send on your employer's system may be viewed by your employer. If this is of concern to you, you should not communicate with SSPC through email.
I have been informed of and understand the risks and procedures involved with using email. I understand that the confidentiality of my individually identifiable health information may be compromised when individually indentifiable health information is sent through electronic transmision via email. I agree to the terms listed above and I hereby voluntarily request the use of email as one form of communication with SSPC.