1. New Patient Paperwork

Patient Information
Patient's Full Name*

First NameMiddle NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Age
Grade
Patient Birth Gender*

MaleFemale
Note:
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list all persons/age living in the home.
Is patient currently in foster care?*

YesNo
Parent/Guardian Information
Mother/Guardian's Name*

First NameLast Name
Mother's Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Email Address*
example@example.com
Mother's Cell Phone*

Area CodePhone Number
Mother's Alternate Number

Area CodePhone Number
Mother's Occupation/Employer
Mother's Marital Status
Father/Guardian's Name*

First NameLast Name
Father's Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Email Address*
example@example.com
Father's Cell Phone*

Area CodePhone Number
Father's Alternative Phone

Area CodePhone Number
Father's Occupation/Employer
Father's Marital Status
May we leave a voicemail and/or text message regarding appointment or continuing care on your voicemail?*

YesNo
If yes, which parent/guardians should receive the text number for appointment reminders?*

Insurance Information
Primary Insurance Company*
Policyholder Name*
SSN of Policyholder
Relationship to Patient
Policyholder Date of Birth

MonthDayYear
Date
Policyholder Employer
Primary Insurance Policy #
Primary Insurance Group #
Do you have a secondary insurance?*

YesNo
Secondary Insurance
Secondary Insurance Policyholder & DOB
Secondary Insurance Policy #
Secondary Insurance Group #
I certify that I, and/or my dependents have insurance coverage described above and authorize payment directly to Jodi Gilray PT, PLLC or all insurancebenefits, if any, otherwise payable to me for services rendered on my behalf or my dependents. The above-name may use my health care informationand may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services anddetermining benefits payable for related services. I authorize the use of my signature on all insurance submissions
Signature*

Clear
Referral Sources
Pediatrician*
Referring Physician (if different)
Specialty Physician
What is the current reason for coming to therapy?*
Previous or current PT, OT, SLP (List all types, dates, providers, and duration)
How did you hear about us? *
If you want to specify who referred you to us please do so here. Thank you!
Medical History
Please list any other pertinent medical information including surgical history and/or explain any boxes checked "Yes."

Check all that apply and explain any boxes marked yes.

	Yes	No	Explain
Delays in Development
Learning Difficulties
Torticollis
Plagiocephaly
Speech Delays/Difficulties
Feeding Difficulties
Reflux
G-Tube Placement
Hearing Aids
Glasses/contacts
Eye Surgery
Frequent Ear Infections
Frequent infections (other)
Ear Tubes
Tonsillectomy
Appendectomy
Diabetes
Thyroid/Lupus/Arthritis
Spina Bifida
Pain
History of trauma
History of abuse/ neglect
Abnormal gait/run
Walks on toes
Frequent Falls
Orthotics/ prosthetics
Hip subluxation/ dislocation
Contractures
Fractures
Seizure disorder
Cerebral Palsy
Hydrocephalus/ shunt
Head injury
Depressed mood
Autism
ADD/ADHD
Anxiety
Surgeries
Pneumonia
Breathing problems
Lung disease
Asthma
Tracheostomy
Heart Murmur
Congenital heart defect
Patent ductus arterioles
Cardiac surgery
Snores/ night terrors
Sleep problems
Dizziness
Fatigue
Cancer

Surgical History /Dates
Please list any other pertinent medical information.

Have you had any Diagnostic Imaging?

	Yes	Type, Date & Location
X-Ray
MRI
CT Scan
EEG
Ultrasound
Swallow Study
Other

Please upload any pertinent medical records.

Browse Files
Upload Cancelof
Medications
Please list any medications and dosage. Include prescription, over the counter, herbals, vitamins/minerals, dietary supplements.
Does you child take any medications?*

YesNo
Please list medication(s) and dosage here :
Does the patient have any allergies?*
If yes, what allergies?
What is the reaction(s) to the allergies listed above ?
Birth / Developmental History

Please fill out this section if your child is less than 5 years old.

	Yes	How many weeks gestation?
Full Term
Pre-Term

Birth weight
Current weight
Was the Pregnancy

SingleTwins
If pregnancy was complicated please explain here.

Describe any drug exposure in utero.

	Yes	No	Describe
Prescription Medication
Illegal Substances
Alcohol
Other

Delivery

VaginalPlanned C-sectionEmergency C-sectionOther
Were there complications with delivery?
Was the child placed in Newborn Intensive Care Unit (NICU)?
If yes , how long?
Did your child pass the newborn hearing screen?

YesNo
Please describe any other medical issues or complications during pregnancy, at birth or after.
Please describe any feeding/latching difficulties your child experienced.

Please check all that apply to your child as an infant.

	Yes
Fussy
Active
Feeding difficulties
Quiet
Calm
Always "on the go"
Floppy
Easy baby
Sensitive
Stiff
Spit up often
Poor sleep patterns

Please Indicate the approximate age your child acheived the following milestones.
Speech Development Additional Comments
Cooing Insert age Babbling/JargoningInsert age
First Word Insert age & word Put 2 words togetherInsert age
Physical DevelopmentAdditional Comments
Rolled Insert age Sat alone Insert age
Crawled Insert agePulled to stand Insert age
Walked alone Insert age Dressed SelfInsert age
Clapped hands Insert age Fed Self Insert age
Ride a bike Insert age Pump swingInsert age
Patient Health Questionnaire

Please fill out this section if your child is experiencing pain.
Describe your pain or symptoms (i.e ache, deep, sharp, stabbing, hot cold, sensitive, sharp, itchy)
When did your symptoms begin?
Did symptoms occur suddenly, gradually, or due to an accident or activity?
What causes or increases your pain?
What relieves your symptoms?
Do you have difficulties with your job or schooling due to pain?
Explain
What daily activities are you limited or unable to do because of your pain? (be specific)
What physical or extracurricular activities do you normally participate in ?
If you have pain, rate the intensity on the scale below:
At Best?
At Worst?
In Morning?
At Night?
Scheduling & Attendance Policy

You may have a copy of this policy.
Regular attendance is required of all patients scheduled as patients will not benefit from sporadic therapy. We do our best to accommodate all patients but after school appointments are our busiest time. To ensure regular treatment, we ask that you consider varying your time of appointments as much as possible.

1. Scheduling Policy: Scheduling is done on the first day of the month for the following month by calling into the office and leaving a message. You will be called back the same day by someone who will schedule your child. Please contact us again if you don’t get a same day call back. There are exceptions for scheduling for new patients.

2. Cancellation Policy: If a patient is unable to keep an appointment for a therapy session, the clinic should be notified a minimum 24 hours in advance. The voicemail is available 24 hours a day. Please state the reason for cancellation. Appointment reminders are texted as a courtesy to families the business day before their appointment to allow us time to move through our waitlist and help another child receive therapy.

3. Flex Schedule Policy: Because we do not charge for missed appointments and we try to accommodate all patients, we hold our cancellation policies strictly. Patients with 2 cancellations in an 8 week period without minimum notice will be placed on our flex schedule, which means your child will only be scheduled 1-2 weeks in advance. Your future appointments will be offered to children on our waitlist. Our front office will do their best to notify you of openings in the schedule and offer them to you but it is your responsibility to call our office and ask about scheduling your child. After 2 months of flex schedule with good attendance, there is an option to return to advanced/priority scheduling.

4. When patients are consistently late, the therapist has the discretion to treat or cancel appointment.

5. Parents are not required to do so unless requested by a therapist for therapeutic educational purposes. Children over the age of 2 years generally perform better without the parent in the room. Parents are encouraged to remain on the premises should a need arise.

6. MercyCare does not permit biological parents to attend therapy sessions and they will be asked to wait in the waiting room should they arrive.

7. AHCCCS provides free transportation to all medical appointments with 3 days advance notice. Contact your insurance payor for details and to set up the rides.

8. Please contact management if special consideration is needed, or if you have any questions regarding these policies.
My signature below indicates that I have read, understand and agree to the terms of the scheduling and attendance policies.
Parent/Guardian's Signature*

Clear
Date*

MonthDayYear
Date
Consent to Treat & HIPAA Authorization
Our practice is required by law to maintain the privacy of your health information. We are dedicated to maintaining the confidentiality of your health information.

I hereby authorize treatment and use/disclosure of protected health information about my child as described below:

1. I understand that I have the right to ask and have any questions answered prior to receiving treatment, including any risks or alternatives to the treatment plan that has been prescribed by me. By signing below, I consent to have a therapist employed/contracted by Jodi Gilray PT, PLLC provide treatment. Should I be unable to bring my child in for therapy, a signed release to have a friend/family member bring the child in will serve as my consent to treat.

2. Jodi Gilray PT, PLLC and its employees/contractors are authorized to use or disclose health information that is pertinent or required for therapy purposes. I have a right to a paper copy of the Notice of Privacy Practices at any time.

3. I understand that Jodi Gilray PT, PLLC may be disclosing protected health information to a patient’s insurance company and physician for continuing care. I also understand that the information used or disclosed may be subject to multiple disclosures by the individual or facility receiving the information. Upon written request, I have a right to a copy of my child’s health information, including medical records and billing records and may be charged the reasonable cost based fee imposed by Jodi Gilray PT, PLLC.

4. I may revoke the authorization by notifying Jodi Gilray PT, PLLC in writing. However, I understand that any action taken previously to revoke this authorization cannot be reversed, and my revocation will not affect those actions. The authorization expires when a patient is discharged by Jodi Gilray PT, PLLC or when written notice to revoke authorization is received. Prior notification will be given to the parent or guardian before information is released.

5. I do hereby give my consent for speech, occupational and physical therapy according to the guidelines established by the referring physician and the therapist. In doing so, I understand, acknowledge and affirm that such rehabilitation and related services may involve bodily contact, touching and/or direct contact, within the scope of each practitioner’s license to practice in Arizona.

6. I, as parent/guardian of minor receiving treatment, do hereby agree and understand that I have been advised to remain on the premises during any such treatment, and waive any claim I may have resulting from failure to do so.
I know and agree that Jodi Gilray, PT PLLC is not responsible for loss or damage of personal valuables.

7. I consent to the use and disclosure of medical information for business operations including credit card processing and online HIPAA compliant medical scribes to conduct operational, cost-management and business planning activities for our practice. These uses and disclosures are important to ensure that you receive quality care and that our practice is well run.
I hereby authorize treatment and use/disclosure of protected health information about my child as described above.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Payment/ Insurance Policy
Jodi Gilray Pediatric Therapy is dedicated to proving quality affordable healthcare to all patients. Please check a box that applies to your insurance/payment options below. By checking a box in the desigated options below you are confirming the type of insurance that you will be using.
Select one*

Private Insurance Patients: I understand that my private primary and secondary insurance will be billed for my child's therapy services. Jodi Gilray Pediatric Therapy will file all charges incurred with your insurance company. All co-payments are due at time of service. Any unpaid balance will be transferred to you and we will discuss available payment policies if needed. Knowing your insurance benefits is your responsibility. Although we verify your insurance as a courtesy, you are strongly encouraged to contact your insurance company with any questions regarding your policy. I will inform Jodi Gilray Pediatric Therapy immediately of any changes in insurance coverage or providers.Medicaid/AHCCCS Patients: I understand that I am financially responsible for all charges incurred if my child's AHCCCS is terminated for any reason. I agree that I will maintain eligibility and renew annually. I agree to pay $225.00 for the initial evaluation and then $98.00 per treatment at the time of service should my eligibility run out.Self-Pay Patients: I understand that I am responsible for all charges incurred at Jodi Gilray Pediatric Therapy and will be held liable for payments in full. I agree to pay $225.00 for the initial evaluation and then $98 per treatment at the time of service. We will discuss available payment policies if needed.MercyCare Patients: I understand that I am responsible to inform Jodi Gilray Pediatric Therapy of any changes in coverage and/or guardianship.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Patient Information

Parent/Guardian Information

Insurance Information

Referral Sources

Medical History

Medications

Birth / Developmental History

Patient Health Questionnaire

Scheduling & Attendance Policy

Consent to Treat & HIPAA Authorization

Payment/ Insurance Policy