Vibrant Beginnings Intake Form

1. I consent to my child receiving Occupational Therapy services from Balanced Babies OT, PLLC and I will participate to my capability along with my child in the therapy services provided.

 

2. I consent to my child receiving Occupational Therapy services from Balanced Babies OT, PLLC as prescribed by a physician and/or recommended by an occupational therapist. I understand that care will be provided by a qualified, licensed, and trained health professional. 

 

3. I understand and am informed that minimal risk may be involved. I understand that I have the right to ask about these risks and have any questions answered about my child’s condition prior to treatment. 

 

4. I acknowledge and agree that a parent or legal guardian must be present during each treatment session. 

 

5. I consent to my child receiving Occupational Therapy services through telehealth (phone and/or video) if required when in-person session are not available and services can be realistically carried out via telehealth means.

 

6. I acknowledge and agree that telehealth and conferencing technology comes with inherent risks of privacy security and that while all reasonable measures are taken to secure my personal health information, no technology interface is fully secure.   

 

7. I have carefully read and fully understand this informed consent form and have had an opportunity to discuss it with the treating therapist.  I understand that I may withdraw my consent regarding evaluation and therapy at any time.

 

By signing below, I authorize and request Balanced Babies OT, PLLC to administer all necessary treatments and care required for my child’s treatment. This consent is effective from the date it is executed until the date the client terminates it in writing. 

After your consultation appointment, Dr. Amy and Dr. Jill will make a decision on whether or not your child would benefit from a tongue, lip, or buccal tie release. If treatment is recommended, you will be given the following consent form. Please feel free to review this form in advance of your appointment and present any questions or concerns to Dr. Amy at your appointment.

 

Diagnosis:

After a careful oral examination of my child’s mouth, Dr. Amy has identified restrictive tension/shortened frenula tissue under the tongue (lingual frenulum), central upper lip (labial frenulum) or cheek areas (buccal frenula). The restrictive tissue may be related to symptoms experienced.

Such tethered oral tissues can limit function during breastfeeding or bottle-feeding, chewing and swallowing, articulation and can affect maxillofacial development, orofacial muscle tension, and sleep patterns.

 

Recommended Treatment:

In order to treat this condition, Dr. Amy has recommended a frenectomy (a procedure to release the tight frenula tissue). Your child will be swaddled and safety goggles will be placed. A CO2 laser will then be used to release the restrictive frenula tissue. Depending on the child’s age, a bite block may be used to keep the mouth open during the procedure.

 
The treatment may help accomplish the following:

Allow the tongue/lip/cheeks to move in a greater range of motion
Improve breastfeeding/bottle-feeding comfort and efficiency
Improve reflux/digestive symptoms, body tension, oral posture and/or sleep patterns
Reduce the severity of speech and eating difficulties

 

Risks and complications of this treatment include but are not limited to:

Lack of improvement
Post-surgical bleeding, pain, swelling, feeding aversion
Re-attachment of the frenulum or development of scar tissue that may cause a return of the original symptoms
Possible need for a second procedure (if the initial results are not satisfactory)
Injury to adjacent structures: salivary glands, ducts, nerve, muscle and skin
Rare possibility: infection, numbness, allergic reaction, aspiration

 
Very rare possibility:
Vitamin K deficiency bleeding or other undiagnosed bleeding disorder
Complications due to underlying medical conditions

 

Supplemental records and their use:

I consent to photography and filming of my child’s oral structures and/or release procedure for educational use in lectures, social media, or publications provided my child’s identity is not revealed

 

Necessary follow-up and self-care:

I understand that it is my responsibility to adhere to wound care instructions and follow up appropriately with recommended health care professionals (IBCLC/bodyworker/SLP/OT etc). I will need to come for post-op appointments with Dr. Amy so she can monitor and evaluate my child’s healing. Failure to comply could lead to an unsatisfactory or sub-optimal outcome. 

 

I have read and fully understand the terms and words within this document. The benefits and possible risks were discussed as well as alternative care options, including no treatment or bodywork/oral motor therapy. 

This notice describes how health information may be used and disclosed and how you can get access to this information. Please review it carefully. 

1. Our pledge regarding health information
   We understand that health information about you and your health care is personal. We are committed to protecting health information about your child. We create a record of the care and services your child receives from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your child’s care generated by this practice. This notice will tell you about the ways in which we may use and disclose health information about your child. We also describe certain obligations we have regarding the use and disclosure of your child’s health information. We are required by law to:
   1. Make sure that protected health information (PHI) that identifies your child is kept private.
   2. Give you this notice of our legal duties and privacy practices with respect to health information
   3. Follow the terms of the notice that is currently in effect.
   4. We can change the terms of this notice, and such changes will apply to all information we have about your child. The new notice will be available upon request.
2. How we may use and disclose health information about your child:
   1. The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information will fall within one of the categories.
      1. For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/ client to use or disclose the patient/ client’s personal health information without the patient’s written authorization, to carry out the healthcare provider’s own treatment, payment or health care operations. We may also disclose your child’s protected health information for the treatment activities of any health care provider. This too can be done without your written authorization.
         1. For example, if a health care provider were to consult with another licensed  health care provider about your child’s condition, we would be permitted to use and disclose your child’s personal health information, which is otherwise confidential, in order to assist the health care provider in diagnosis and treatment of your child’s condition. Disclosures for treatment purposes are not limited to the minimum necessary standard. Because other health providers need access to the full record and /or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.
      2. Lawsuits and Disputes: If you are involved in a lawsuit, we may disclose health information in response to a court or administrative order. We may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request to obtain an order protecting the information requested.
3. Certain Uses and Disclosures Require Your Authorization:
   1. Session Notes: we do keep “session notes” and any use or disclosure of such notes requires your Authorization unless the use or disclosure is"
      1. For our use in treating your child
      2. For our use in training or supervising associates to help them improve their clinical skills
      3. For my use in defending ourselves in legal proceedings instituted by you
      4. For use by the Secretary of Health and Human Services to investigate our compliance with HIPAA
      5. Required by law and the use or disclosure is limited to the requirements of such law.
      6. Required by law for certain health oversight activities pertaining to the originator of the session notes.
      7. Required by a coroner who is performing duties authorized by law.
      8. Required to help avert a serious threat to the health and safety of others.
   2. Marketing Purposes: As healthcare providers, we will not sell your child’s PHI for marketing purposes.
   3. Sale of PHI: As healthcare providers, we will not sell your PHI in the regular course of our business.
4. Certain Uses and Disclosures Do Not Require Your Authorization
   1. Subject to certain limitations in the law, we can use and disclose your child’s PHI without your Authorization for the following reasons:
      1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
      2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
      3. For health oversight activities, including audits and investigations.
      4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
      5. For law enforcement purposes, including reporting crimes occurring on my premises.
      6. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counterintelligence operations; or helping to ensure the safety of those working within the housed in correctional institutions.
      7. For workers’ compensation purposes. Although our preference is to obtain an authorization from you, we may provide your child’s PHI in order to comply with workers’ compensation laws.
      8. Appointment reminders and health related benefits or services. We may use and disclose your child’s PHI to contact you to remind you that you have an appointment with us. We may also use and disclose your child’s PHI to tell you about treatment alternatives, or other health care services or benefits that we offer.
5. Certain Uses and Disclosures Require You to Have the Opportunity to Object
   1. Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other person that you indicate is involved in your child’s care or the payment for your child’s health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
6. You have the Following Rights with Respect to Your Child’s PHI:
   1. The Right to Request Limits on Uses and Disclosures of your child’s PHI. You have the right to ask us not to use or disclose certain PHI for treatment, payment, or health care operations purposes. We are not required to agree to your request, and we may say “no” if we believe it would affect your child’s health care.
   2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid in Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
   3. The Right to Choose How We Send PHI to You. You have the right to ask us to contact you in a specific way (for example home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.
   4. The Right to See and Get Copies of Your Child’s PHI. Other than “session notes,” you have the right to get an electronic or paper copy or your child’s medical record and other information that we have about your child. We will provide you with a copy of your child’s record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and we may charge a reasonable, cost based fee for doing so.
   5. The Right to Get a List of the Disclosures We Have Made. You have the right to request a list of instances in which we have disclosed your child’s PHI for purposes other than treatment, payment, or health care operations, or for which you provided us with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost based fee for each additional request.
   6. The Right to Correct or Update Your Child’s PHI. If you believe that there is a mistake in your child’s PHI, or that a piece of important information is missing from your child’s PHI, you have the right to request that we correct the existing information or add the missing information. We may say “no” to your request, but we will tell you why in writing within 60 days of receiving your request.
   7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right to get a paper copy or this Notice, and you have the right to get the electronic copy of this notice by email. And, even if you have agreed to receive this Notice via email, you also have the right to request a paper copy of it. 

 

Effective Date of this Notice

This Notice went into effect on March 4, 2023

 
Acknowledgement of Receipt of Privacy Notice 

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your child’s protected health information. By signing below, you acknowledge that you have read the notice of privacy practices and have received a copy of HIPAA Notice of Privacy Practices. 

Attendance and Cancellation:

In order to better serve you and make quicker progress towards goals, regular attendance to therapy is imperative. We ask you follow the attendance policies outlined below: 

1. Cancellations: Please call at least 24 hours in advance to cancel your appointment. There is no guarantee that a make-up session will be scheduled. Excessive cancellations may result in termination of therapy services. Any cancellation within 24 hours of an appointment will incur a fee of $50.
2. No Shows: A “no show” is a non-attendance without prior notification. Any “no show” will incur a fee of $99. Repeated late cancellations and no-shows will result in discharge from the practice.
3. Late for Appointments: If you are more than 15 minutes late, we reserve the right to cancel the appointment and consider it a cancellation (see policy for cancellations above).
4. Clinician Cancellations: If your providers are not able to attend your appointment, you will be contacted as soon as possible. Please be sure that our office knows the best way to reach you. Every effort will be made to reschedule your appointment in a timely manner. 
5. Reminders: As a courtesy, Vibrant Beginnings may send an email or text reminder the day before a scheduled appointment. I recognize that my attendance is not dependent upon the receipt of an email reminder. 

 

Insurance and Payment:

This payment policy is an agreement between you and Vibrant Beginnings for payment of services provided. By signing this policy you are agreeing to pay for services provided to you or your family member. 

Insurance: We are not in network with insurance companies. However, we will bill your dental insurance as a courtesy. 

We bill for the following dental codes:

Consult: D0150

Lingual Frenectomy: D7962

Maxillary Labial Frenectomy: D7961

 

If you are planning to file a claim for reimbursement through your medical insurance, you are responsible for checking with your insurance provider before your first visit to find out what occupational therapy services and tethered oral tissue releases services they will pay for, or if your insurance company requires a physician's referral and pre-authorization from your insurance company. At the completion of your treatment, we will provide you with a Superbill to submit to your medical insurance. Please see the document attached to your intake email with the codes we can submit to your medical insurance on your Superbill.

Payment of Fees: I understand that Vibrant Beginnings requires fees to be paid at the time of service.

1. Session billing is an inclusive fee for the time associated with the sessions to prepare, document, provide treatment, and follow-up visits, as well as communication between sessions. 
2. Rates of Services:
   1. Consultation: $350
      1. Includes comprehensive assessment by DDS and OT; Complete Occupational Therapy session with Balanced Babies, OT & customized treatment plan for your baby; Complete Oral Assessment with Dr. Amy Weis
   2. Tongue/Lip/Buccal Tie Release: $950
      1. Includes release of tissues, all release sites included with no additional charge for additional sites
      2. Two post-operative healing follow-ups by Dr. Amy: typically 2-day and 1 week
      3. One functional follow-up occupational therapy treatment session with Balanced Babies, OT, PLLC to ensure your child's proper function
   3. Additional Occupational Therapy Visits: $100
      1. Your baby may require additional therapy sessions before or after frenectomy treatment, based on their existing compensation and suck patterns. If our providers recommend additional therapy that would benefit your child and the ultimate successful outcome of treatment, these therapy sessions will be an additional and separate fee from those of the Consultation and Release + Follow-up fees listed above. Any additional therapy session fees will be discussed with you during your visit.
3. Payment Options: We accept payment by cash, check, Health Savings Account (HSA), Flexible Spending Account (FSA), debit or credit card. Returned checks will incur a $35 service fee. Payment is due at the time of service.

 

Contact Person/ Provider: Amy Weis, DDS

(828) 693-7246

vibrantdentalcompany@gmail.com

1004 Asheville Highway, Hendersonville, NC 28791

 
National Provider Identifier (NPI): 1316423650

NC License: DDS # 12662

 

 

Contact Person/ Provider: Jill Johnston, OTD, OTR/L  

(828) 393-0066

jill@balancedbabiesot.com           

4 Long Shoals Road Ste. 435 Arden, NC, 28704                  

 
Employer Identification Number (EIN): 87-4080212

National Provider Identifier (NPI): 1891206058

NC License: OT # 13316

 

This Notice went into effect on March 4, 2023

 
By signing below I am agreeing that I have read, understood, and agree to the items contained in this document.

I understand and agree to all of the terms stated above. 

The following is an explanation of the Good Faith Estimate under the “No Surprises Act,” a federal law that became effective January 1, 2022.

This Good Faith Estimate shows the costs of items and services that are reasonably expected for health care needs for an item or service. The estimate is based on information known at the time that estimate was created and is not a contract for services. You are in no way obligated to schedule or pay for the number of services listed on a Good Faith Estimate.

Federal Law states that any Good Faith Estimate given to a client/patient does not include unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.

You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process.

If the agency reviewing the individual’s dispute agrees with the individual, the provider/facility will have to pay the price on this Good Faith Estimate. If the agency disagrees with the individual and agrees with the health care provider or facility, the individual will have to pay the higher amount.

To learn more or to get a form to start the process, go to www.cms.gov/nosurprises/consumers or call 1-800-985-3059.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059.

Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

 

You may keep this documentation of the good faith estimate or request a copy at any time. For your services with Vibrant Beginnings, you will never be billed more than $300 for a consultation and $850 for treatment, including 1 follow-up therapy visit with Balanced Babies, OT, PLLC and 2 healing follow-up visits with Dr. Amy of Vibrant Beginnings, unless agreed upon in advance of the session due to a pre-announced rate change. You reserve the right to refuse treatment at any time. Additional follow-up or therapy visits outside of what is included in consultation and treatment fees will incur additional charges.

Please note all charges are due at the time of service.

Vibrant Beginnings charges:

1. Consultation: $350
   1. Includes comprehensive assessment by DDS and OT; Occupational Therapy session with Balanced Babies, OT; Customized Treatment Plan; Complete Oral Assessment with Dr. Amy

1. Tongue/Lip/Buccal Tie Release: $950
   1. Includes release of tissues (no additional charge for additional release sites)
   2. Two post-operative healing follow-ups by Dr. Amy
   3. One functional follow-up occupational therapy treatment session with Balanced Babies, OT, PLLC.
2. Additional Occupational Therapy Visits: $100
   1.  Your baby may require additional therapy sessions before or after frenectomy treatment, based on their existing compensation and suck patterns. If our providers recommend additional therapy that would benefit your child and the ultimate successful outcome of treatment, these therapy sessions will be an additional and separate fee from those of the fees listed above. Any additional therapy sessions needed will be discussed with you during your visit.

Depending on the client's individual needs, and concerns/preferences of the family, each plan of care and length of service will vary for each client. Frequency and duration of services are recommended by the provider and mutually decided as a team with the family. 

 

Effective Date of this Notice

This Notice went into effect on March 4, 2023

 
By signing below I am agreeing that I have read, understood, and agree to the items contained in this document. Additionally, I have read the good faith estimate and understand my rights to dispute and/or request an updated good faith estimate at any time.

I understand and agree to all of the terms stated above.