The information provided on this form will assist in planning and providing the appropriate services for your child. All information will be a part of the child's record and will be confidential. Information may be stated in the report unless requested that it be kept private.

I hereby authorize the release/disclosure of the information originated by Pediatrics Unlimited Inc. I understand information may be mailed, faxed, or electronically transmitted when necessary. I understand that this authorization may last up to one year but can be revoked verbally or in writing by the authorized person(s).

I understand that electronic transmission of information includes email, instant messaging and web-based video conferencing. Email is frequently the most efficient way for school and Pediatrics Unlimited staff to communicate between agency providers. The limitation of electronic transmission of information is that we cannot ultimately guarantee their security. Precautions will include initial verification of email addresses and online identities before clinical information is transmitted.

For the Purpose of: I acknowledge that all information I authorize to be released or requested will be held strictly confidential and cannot be released by the recipient without additional written consent. A copy of this authorization is valid in lieu of the original. I further understand I may withdraw my consent in writing at any time.

The photograph/videotape will not be used for any other purposes than those authorized on this form. For the privacy of others, taking pictures and videos in common areas is prohibited.

I understand I am responsible for contacting my insurance company or primary care physician to verify benefits and for authorization of any visits to Pediatrics Unlimited, Inc. I understand I am responsible for all costs not covered by my Insurance Company. These costs include, but are not limited to: Services provided which are not covered by my policy; balances after insurance payment; or failure to obtain authorization before my appointments. I understand that co-pays are paid at the time service is rendered unless other arrangements are made.  Any outstanding payments will be due by the last business day of the month to avoid interruption of services and additional charges.  If a payment is not paid by the last business day of the month, a late fee of $25 will be billed to my account. After 3 consecutive late fees, therapy services will be terminated and collective action will be initiated.  Account balances that are paid promptly will avoid these charges. I understand any overpayments I make on my account that create a balance of $10 or less will not have a check issued for refund.

I understand that my insurance will not be filed until the date that I provide a copy of the patient's insurance card/number. Insurance will not be filed retroactively.

I hereby authorize Pediatrics Unlimited to release to any insurance company or liable third parties any records or information regarding the diagnosis, condition or treatment of the patient. I am agreeing to assignment to Pediatrics Unlimited all payments from insurance companies for therapy services rendered.                                                                                                                            

I have authorized services at Pediatrics Unlimited and understand that I will be billed by the 7th of each month for outstanding balances. The bill must be paid by the last business day of the month. All checks are to be made payable to Pediatrics Unlimited. All service charges for any checks returned for Insufficient Funds is my responsibility.

I understand my benefits information available at the time of my evaluation. I understand my deductible; copay & coinsurance responsibility is available upon request. I understand that this information is not a guarantee of coverage but is only representative of the information available from my insurance company at the time it was researched. 

I understand that all fees are non-negotiable.

I understand that I am required to call a minimum of 24 hours prior to scheduled appointments to cancel, otherwise it will be considered a No Show. Two No Shows in 6 months, and/or 3 weeks of cancelled appointments in a row will result in the loss of my standing therapy appointments and additional fees. I understand that I am required to maintain 70% attendance per quarter and no more than 3 Late Arrivals or Pick-Ups per 6 months. A late arrival is defined as missing 15 minutes or more of a session. A late pick-up is defined as not being present at least 15 minutes before your child's session ends. Failure to meet this criteria can result in the loss of regular appointment spots and additional fees.

It does become necessary from time to time to cancel your appointments due to therapist illness or absence. These cancellations will not be counted against you.

 

I understand that if my child is admitted to the hospital as an inpatient, Pediatrics Unlimited will need new orders/release for therapy services to resume. These orders should include any restrictions that the child may have.

I understand smoking is not permitted on the premises. Failure to comply will result in loss of therapy appointment(s).

WELCOME TO PEDIATRICS UNLIMITED

We are pleased you have chosen our clinic to assist your child with their therapy needs.  Our staff includes Physical Therapists, Occupational Therapists, and Speech Language Pathologists. Our goal is to provide quality services to your child. You are the expert on your child and our pediatric team members are experts in their specialty.  Together we can help your child improve specific skills and help them reach their full potential. You and your child have rights and responsibilities. We want you to understand these rights and responsibilities so you can help us to provide better service to your child. Please read and sign at the bottom of this statement.

RIGHTS:

DIGNITY: You and your child have the right to be treated with dignity regardless of race, sex, or religious preference.

PRIVACY: Your medical records are private. A complete discussion of your privacy rights is included in the “Notice of Privacy Practices”.

PARTICIPATION: It is usually in the best interest of the child for family to participate in therapy for either a whole or part of the session.  If this is not possible, we may take a few minutes at the end of the therapy session to consult with you on how the treatment session went and what you can work on at home.  You will receive personalized reports every 9 months. A progress summary is recorded once per quarter in your child's electronic medical record.

RESPONSIBILTIES:

CANCELLATIONS, NO SHOWS, LATE ARRIVALS, & LATE PICK-UPS: We understand that many things occur when dealing with children; however, you have the responsibility to keep scheduled appointments. Usually you will have regularly scheduled appointments that are the same from week to week.  Cancellations:  If you need to cancel an appointment, you will be given the opportunity to make up that appointment within one week of the scheduled appointment. No Shows: Your visit will be considered a “No Show” if you did not notify us within 24 hours before the session.  Late arrivals: If you arrive 15 minutes or more late for a half-hour session or 30 minutes or more late for a 1 hour session, you are considered a “Late Arrival.”  Please be aware that therapists may be unable to extend your therapy session if you have a late arrival. Late pick-ups: You need to be present at least 15 minutes before your child's therapy session ends. Otherwise, you will be counted as a "Late Pick-Up."

If you have 3 weeks of Cancellations, 2 No Shows in 6 months, or 2 consecutive Late Arrivals and/or Late Pick-Ups, you will be asked to schedule appointments on a week-to-week basis and/or attend a Consult Session with a member of management. You are required to attend 70% of therapy sessions per quarter with no more than 25% late arrivals. Failure to meet this criteria can result in loss of your child's regular appointment spot(s) and additional fees.

SUPERVISION: You are responsible for supervision of children you bring  to our clinic. We encourage you to remain on the clinic property during your child’s therapy session.  If you do need to leave, please give your cell number or a number you can be reached at by the office staff.

ILLNESS: Please do not bring your children if they are sick. If they are not feeling well, they will not be ready to learn. Fevers, pink eye, stomach viruses, and other contagious illnesses should be reasons to reschedule your appointment.  A child must be fever free for 24 hours before attending a therapy session.

CONCEALABLE WEAPONS:  Pediatrics Unlimited Inc prohibits the possession of firearms or other weapons on company property.

CELL PHONES:  We would like for your child to receive full benefit from their time here.  So, when you are in therapy sessions we ask that you put your cell phone on a silent ring and only answer emergency calls, so that it doesn’t distract your child and therapist.

Pediatrics Unlimited is a privately owned practice. If your child needs additional services, we can direct you to those agencies.  Pediatrics Unlimited is a teaching facility.  If you do not want a student involved in your child’s plan of care, please let your treating therapist know.

Signing this page indicates that you understand your rights and responsibilities and give your permission to Pediatrics Unlimited, Inc. to provide therapy services to your child.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice please contact: 

Alex Maxwell, Privacy Officer

Or

Tara Adams, Security Officer

This Notice of Privacy Practices describes how we may use and disclose protected health information to carry out treatment, payment or health care operations.  It also describes your rights to access and control your protected health information.  “Protected Health Information” is information about you, including demographic information that may identify you and that relates to your past, present or future physical or mental health and related health care services.

Pediatrics Unlimited is required to abide by the terms of this Notice of Privacy Practices.  We may change our notice at any time.  The new notice will be effective for all protected health information.  Upon your request, we will provide you with any revised Notice of Privacy Practices by requesting that information in writing.  A revised copy will be given to you within 30 days.

I. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

You will be asked by our office to sign a consent form.  Once you have consented to use and disclosure of your protected health information for treatment, payment and health care operations. Pediatrics Unlimited will use or disclose your protected health information as described below Your protected health information may be used and disclosed by our therapists, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you.  Your protected health information may also be used to pay your health care bills.

The following are examples of the types of uses and disclosures of your protected health care that our office is permitted to make once you have signed our consent form.  These are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office once your have provided consent.

1. Treatment We will use and disclose your protected health information to provide and coordinate your care and any related service. This includes coordination or management of your care with a third party that has already obtained your permission to have access to your protected health information. For example, we would disclose your protected health information, as necessary to any health agency that provides care to you.  We will also disclose protected health information to a physician who is or will be treating you.

2. Payment When needed, we will disclose your protected health information to obtain payment for services. This may include disclosures to you health insurer to get approval for a recommended therapy, to determine whether you are eligible for benefits, to determine whether a particular service is covered under your health plan, and when required for utilization review activities.

3. Health Care Operations Pediatrics Unlimited may use or disclose your protected health information for management or administration of the clinic. Health Care operations may include:  (1) quality control and improvement activities (2)  staff review and and training (3) certification, licensing and credentialing activities (4) health care audits by third party payers (5) calling your name during for your regularly scheduled appointment (6) contacting you to remind you of an appointment (6) newsletters about our clinic and the services we offer. We will share your protected health care information with third party “business associates” including billing services for the practice.

As required through your written consent, we will disclose protected health care information to other agencies including but not limited to BabyNet, early intervention programs, and schools.    

Other use of disclosures that may be made without written consent We may disclose your protected health information in the following situations without your authorization: (1) When legally required to comply with any Federal, State, or local laws (2)  When there is a risk to public health such as (a) to prevent disease or injury (b) notification of a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease (3) To report abuse, neglect, or domestic violence (4) Legal proceedings which are in response to a court order (5) For law enforcement purposes to (a) report physical injuries (b) court ordered warrant, subpoena, or summons (c) need to report a crime in emergency situations

Other uses of disclosures that may be made with an opportunity to object The practice may disclose protected health information to a family member or close personal friend if the disclosure is directly relevant to the person’s involvement in your care or payment related to your care.  If you do not object to these disclosures, Pediatrics Unlimited will infer that you do not object, and in its professional judgment that it is in your best interest to disclose information.

Uses and disclosures provided by you Other than the circumstances described above, Pediatrics Unlimited will not disclose your health information unless you provide written authorization. You may revoke your authorization in writing at any time.

II. YOUR RIGHTS

You have the right to inspect and copy your protected health information  You may inspect and obtain a copy of your protected health information that is contained in a designated record set for as long as we maintain the protected health information.  A designated record set is medical and billing records and any other records that the clinic uses to provide services to you.

The clinic may deny your request to inspect or copy protected health information if it is determined that the access requested is likely to endanger the safety of a person, or cause substantial harm to a person referred to in the information.  You have the right to request a review of this decision.

You may not inspect or copy certain records by law, including information compiled for civil, criminal or administrative action or proceeding and protected health information  that is subject to a law that prohibits access to protected health information.

You must submit a written request to Pediatrics Unlimited.  You may be charged a fee for the cost of copying, mailing or other cost incurred to comply with your request.

You have the right to request a restriction of your protected health information You may request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care.  Your request must be in writing and clearly state the restrictions and to whom you want the restrictions to apply.

You have the right to amend your protected health information During the time the clinic maintains your protected health information, you may request an amendment of your information in a designated record set. Request for amendment must be submitted in writing to Pediatrics Unlimited.  Your request must supply a reason to support the requested amendment.  The clinic may deny your request in some instances. You have the right to file a statement of disagreement with us and we  may prepare a rebuttal to your statement. We will provide you with copies of such rebuttal.

You have the right to receive an accounting of certain disclosures we have made  You have the right to request an accounting of the clinic’s disclosures of your protected health information made for purposes other than treatment, payment or health care operations as described in this notice. It excludes notifications we have made to you, for a directory, to friends and family involved in your care, to individuals or agencies which you authorized by signing a release form and certain other disclosures the practice is permitted to make without your authorization.  The request of accounting must be made to our clinic in writing and should state the time period for which you wish the accounting for disclosures to take place.  This is not required for disclosures prior to April 14, 2003.  The clinic will not charge you for the first request of any 12 month period.  Subsequent accountings may require a reasonable fee.

You have the right to a paper copy of this notice.

III. CONTACTS

The clinic’s contact person regarding our duties and your rights under the HIPPA regulations is the Privacy Officer.  Complaints to the clinic should be directed to the Privacy Officer at the following address:

Alex  Maxwell

355 Oak Grove Rd.

Spartanburg, SC 29301

864-595-4225

The Privacy Officer can be contacted by telephone at: 864-595-4225.

I acknowledge that I have read Pediatrics Unlimited, Inc.'s Notice regarding Privacy of Personal Health Information.