Child Background Packet

Physical Therapy Therapy Intake Form
Has your child had any recent evaluations completed?
What are your concerns?*
Can your child ride a bike/tricycle/scooter?*
Can your child do a jumping jack?*
Does your child have any issues with balance or coordination?
What do they look like when they run and go up and down the stairs?
Can your child tolerate movements like swinging and being tipped upside down?*
Does your child go up and down stairs independently? Do they alternate their feet or put both feet on each step?*
Does your child participate in extra curricular activities? Do they swim?*

Release of Information
I hereby consent to the release of information and records regarding my son/daughter 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
I give permission for images/videos of my child captured during treatment sessions to be used solely for the purposes of StoreySmith Pediatric Clinic promotional material and publications on their social media pages or website and waive any rights of compensation or ownership thereto.*

Yes, I give permission.No, I do not give permission.
Parent/Guardian Signature*

Clear

Non-Covered Services Waiver
Cancellation Policy - please print or download for better viewing
Patient Name
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: $125 per hour = $500 - $750 total

Occupational/Speech/Physical Therapy Treatment Session:

Approximate Out of Pocket Cost:
$125 per hour
$72 per 35 minute session
$62.50 per half hour session

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.
Credit card information will be collected prior to or at the time of the appointment to be stored on file.
I hereby authorize StoreySmith Pediatric Clinic, PA to charge the credit card already 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 referenced above for any cancellation ($75.00) not made up within 2 weeks. blanks*
Signature*

Clear

StoreySmith Pediatric Clinic Agreement to Communicate by Email
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.
Client's Name*
I agree to email communication with SSPC.*

I agreeI do not agree
Parent/Guardian Signature*

Clear
Parent/Guardian Name*
Date Signed*

MonthDayYear
Date
Authorized Email Addresses*
Should be Empty:

Child Background Packet

Parent/Guardian 1

Parent/Guardian 2

Child's Medical History

Developmental History

Potential Sources

Physical Therapy Therapy Intake Form

Release of Information

Non-Covered Services Waiver

StoreySmith Pediatric Clinic Agreement to Communicate by Email