Wilson: Patient Intake Form 2025

General Information
Primary Care Provider
Primary Care Provider Phone #
How did you hear about us?
Insurance Information
Name of Responsible Party*
Guarantor Name (if different than Responsible Party)
Guarantor/Responsible Party date of birth*
Name of Insurance*
Member ID #*
Does patient have Secondary insurance?*

YesNo
If yes, please list Insurance Type & Member ID:
I understand that Hogg Therapy Pediatrics (HTP) consists of: The Speech Path, Busy Bee Occupational Therapy and BEH Physical Therapy. While the overarching facility is HTP, I understand that all billing and collections will be under each individual PLLC/LLC as the name appears above, for the designated service my child(ren) receives. This PLLC/LLC name will appear on any explanation of benefits and other insurance documents. By initialing below, I understand the information above.*

FINANCIAL POLICY & PROOF OF INSURANCE: All patients must complete our patient intake forms prior to being seen. Prior to your visit, we will check your benefits, but these are an estimate of your benefits and are subject to claims processing by your insurance. At the time of your initial evaluation we must obtain a copy of the parent/caregiver's drivers license, or a government issued photo ID, as well as current proof of insurance. We will collect estimated patient responsibility at the time of the visit, which may include your deductible, copay and/or coinsurance. Our office accepts cash, Mastercard, Visa and Discover. If you change insurance at any time, you must notify us prior to your visit. Failure to do so may result in you being responsible for the visit cost due to us not being able to obtain prior authorization for the visit. You are responsible for keeping track of approved visits and the number of visits given by your insurance. We track these within our clinic as well, but it is ultimately the responsibility of the member/or responsible party. Please remember that pre-authorization is not a guarantee of payment from your insurance company. Insurance payments are typically received within 30 days from the time of filing. If your insurance company has not made payment within 45 days, we may ask that you contact your insurance company to make sure payment will be made. We are happy to help you with any additional information your insurance company may need, however our office will not enter into a dispute with your insurance company over a claim. If there is no payment activity from your insurance company after 60 days from time of filing, we will ask for you to resolve any outstanding balance(s) on the account. If at any time after you have paid, and your insurance company pays, we will apply the credit to any future visits or reimburse you for the overpayment, once discharged. By initialing, I understand and consent to the information above.*

NOTICE OF BILLING: (Please note that while this section specifically pertains to our clients with private insurance plans, we require all of our incoming clients to understand and agree to our policies). We want to keep you informed of therapy practices that may have an impact on your charges if you have private insurance. First, your fee is based on the services our therapists provide. If our therapists believe a combined therapy or specialized approach would be beneficial for your child, this may increase the cost of that therapy session. Your insurance determines what therapy services are approved and how much you will pay out of pocket for those services. We must follow the insurance processing on your claims with regards to patient responsibility and covered vs not covered services. If you do not agree with how the insurance processed your claim, you will need to be the one to contact them to resolve the issue. Second, your fee could be impacted by the need for evaluation and testing. We must keep up to date progress records for both insurance purposes and to provide the best treatment for your child. In order to maintain these records, we complete a full evaluation at least yearly. If we cannot provide this up-to-date information the insurance may not continue to approve therapy sessions for your child. Evaluations could result in an increased fee for the evaluation session. Third, if your appointments are scheduled prior to or after front desk coverage, or you are seen at a daycare/offsite location, you will be required to put a credit card on file. If you have questions or concerns at any time about your balance, please contact our billing department so they can explain any charges at (859) 353-3666, extension 5. By initialing, you understand the following: that services not covered by my insurance are my responsibility, that an evaluation will be completed yearly, and this may impact my out-of-pocket cost, and that I may be required to have a credit card on file for payments. *

NOTICE OF HIPAA AND PRIVACY PRACTICES: HTP consists of the following entities: The Speech Path, Busy Bee Occupational Therapy and BEH Physical Therapy. They are hereby referred to as Hogg Therapy Pediatrics (HTP). This notice describes how health information about your child may be used and disclosed and how you can get access to this information. The federal government has legislated the Health Information Portability and Accountability Act (HIPAA). The new rules regulate the privacy and accessibility of health information regarding your child's care at HTP. We must follow these privacy practices until changed otherwise. Effective date of 4/14/2003. You may request a copy of this notice at any time, as applicable by law. Any changes added to this form will be made available to you. USE AND DISCLOSURE INFORMATION: Treatment: We may use or disclose your child's health information to plan a course of treatment that includes evaluation, goals and treatment approach. At times, your child's medical information may be reviewed by a student intern at our facility. In addition, your child may receive therapy services in the same room with another child. Within HTP's facilities, your child's goals and data pertinent to your child's treatment may be discussed with others. Payment: We may use and disclose your health information to obtain payment for services we provide to you/your family member. A bill may be sent to you or your health insurance payer. The information on the bill may obtain information that identifies you, your spouse and/or your child. This information may include the child's date of birth, diagnosis and procedures, supplies used, etc. Appointments: We may use or disclose your health information to provide you with appointment reminders (such as emails, text messages, voicemails, etc.).Check In: Your child's name may be called when checking in at our window and/or when being called back for services. Schools & Agencies: We may provide information requested for IEP's, MFE's and evaluations with other healthcare professionals in regard to your child's care with HTP. We may share information with other public health authorities charged with preventing or controlling disease, injury or disability. We will notify appropriate persons if we suspect child abuse or neglect. We may need to provide medical information regarding your child to legal/judicial/administrative and law enforcement personnel. Patient Rights: You have the right to view your child's health record and request a copy of it. There may be a copying and postage fee. You may be asked to show proof of guardianship and/or identity. You may request an amendment to your child's record. We are not required to make this change, but it will be noted in the record. You may restrict anything in our privacy act. We are not required to honor this request but will make all efforts to accommodate reasonable requests. You may fax or mail this to us. Provide written authorization for uses and disclosures not otherwise permitted by law. We may need to send you information regarding your child's care or billing issues through the mail. We may also send you information about groups or programs. This information may come in a marked envelope with our address on it. We will not use or disclose your child's health information without your written authorization. No information regarding other patients may be shared outside the wall of HTP without parental consent. If you believe your privacy rights have been violated, you can file a complaint with our Privacy Officer or with the Secretary of Health and Human Services located at 200 Independence Avenue SW, Washington, DC 20201. By signing below, I certify that I have received a copy of HTP's Notice of HIPAA and Privacy Practices.

Clear

PHOTOGRAPHY RELEASE: I hereby grant permission for Hogg Therapy Pediatrics (HTP) to use mine and/or my child's image in both digital and print formats for official business of the association, including but not limited to: advertising, publications, education, news releases, creative endeavors and posting on the official website at hoggtherapy.com. This certifies that images taken by HTP will become the property of HTP. Images will be used for official association business only and will not be reproduced by the association for personal use.*

I accept and consent for HTP to use mine or my child's image.I decline for HTP to use mine or my child's image.
Initials*
GYM PLAY CONSENT: Gross motor play is often encouraged during therapy. Use of swinging, running, climbing, and jumping assist with a variety of skills and are performance component areas the therapist may need to address. By initialing below I consent to the use of gross motor play. I specifically acknowledge that HTP does not assume responsibility for any injury or the result of injury during the use of gross motor play or within our facilities. In the event injury were to occur, I assume financial responsibility for all services rendered. I furthermore release Hogg Therapy Pediatrics from any liability in the event of injury to my child while participating in activities. By initialing below, I certify that I have carefully read this release and fully understand its contents.*

TELEHEALTH: I understand that I or my healthcare provider or may request to engage in services via telehealth. My healthcare provider would like to express to me how the video conferencing technology used to affect such a consultation, will not be the same as a direct client/healthcare provider visit due to the fact that we will not be in the same room. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing. I understand there are potential risks to technology including interruptions, unauthorized access and technical difficulties. I understand that my healthcare provider or I can discontinue the telehealth consult/visit if it is felt that videoconferencing is not adequate for the situation. By initialing below, I certify that I have read or had this form read to me and that I fully understand its contents including the risks and benefits.*
By signing below, I acknowledge this form in its entirety. I have read and understand all policies presented within this form. All questions have been answered prior to signing.*

Clear
Date*

MonthDayYear
Date
File Upload

Please upload a copy of a photo of your child's insurance card. If your child has a secondary insurance plan please also include a photo of the secondary insurance. include a photo of the front and back of the card
Cancelof

Signature

Clear
Should be Empty:

Authorization to Release Health Information from Wilson Pediatric Therapy to Hogg Therapy Pediatrics:

General Information

Insurance Information