Pediatric New Patient Form

MARYLAND PHONE: (301)-337-7893 OAKLAND PHONE: (510)-631-2753 FAX: (855)754-8261 | EMAIL: INFO@INTEGRITYSPEECHTHERAPY.COM
Child History Form
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.
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number*
Parent's Names*
Home Phone*
Cell Phone*
Email*
example@example.com
Insurance Primary*
Member ID*
Group #*
Insurance Secondary
Member ID
Group #
Please take a photo of the FRONT of your insurance card.
Please take a photo of the BACK of your insurance card.
Child's Address*

Child's Address

Street Address Line 2

CityState

Zip code
School
Grade
Teacher
Child's Doctor*
Doctor's Phone*
Doctor's Fax
Siblings in the household:
Are there siblings living in the household? If no, you may skip to the next question.

YesNo
Name
Age
Name
Age
Name
Age
Reason for referral*
Describe the problem *
Have you received information from other sources about this (e.g., pediatrician, other professionals, family members)? If so, what have you been told?
Please type your answer here*
Is this the first evaluation of this problem?*

YesNo
If no, complete below:
Who/What agency?
When seen?
What outcome?
Medical History
Were there any problems with birth and/or delivery?*

yesno
If yes, please explain:
Is there any history of medical concerns?*

yesno
If yes, please check all that apply:*

visionhearingallergiesseizuresear infectionscoldsinfectionsenlarged tonsilsadenoidsfeeding problemssyndromesno medical concerns
If you checked any of the above items, please explain:*
Is your child on any medications?*

yesno
If yes, please explain:
SPEECH AND LANGUAGE DEVELOPMENT
Age child began babbling*
Age child spoke first words*
Age child used sentences*
Age child began conversing*
Is your child's speech understood by strangers?*

yesno
What are your child's interests and favorite activities?*
Does your child have any fears (e.g. such as stuffed animals, loud noises)?*
If child is in school, are there any concerns about academic performance (e.g., reading, writing, subject areas)?*

yesnoN/A
If yes, please explain:
Has your child received speech therapy previously?*

yesno
If yes, where, and what were major goals?
Does your child receive special help in school?*

yesno
If yes, please explain:
Has the child been evaluated by other professionals (Occupational Therapy, Physical Therapy, etc)?*

yesno
What specialty? (If no type N/A)*
Is there anything else you wish to add that would help insure a positive testing experience for your child?*
Name of person completing this form*

First NameLast Name
Signature of person completing this form*

Clear
CONSENT FOR SERVICES
I authorize Integrity Speech Therapy to render appropriate evaluation and therapy services to the client named below in accordance with state and federal laws. I understand that care will be provided by a qualified, licensed, and trained health professional. I recognize, agree and understand that I have the right to refuse treatment or terminate services at any time by Integrity Speech Therapy in writing. In addition, Integrity Speech Therapy may terminate services by notifying me in writing.I do not give my consent or I am withdrawing my consent regarding Integrity Speech Therapy rendering evaluation and/or therapy services to the client named below.
Name of Client*
Date*

MonthDayYear
Date
Client Date of Birth*

MonthDayYear
Date
Signature of Client or Legal Representative*

Clear
AUTHORIZATION FOR RELEASE AND/OR REQUEST FOR INFORMATION
I hereby request and authorize Integrity Speech Therapy in verbal and/or written communication with release of records, and to engage in communications via email/mail regarding the information checked below concerning patient:
Name of patient*
Whose date of birth is*

MonthDayYear
Date
I understand that information concerning psychiatric, psychological, medical diagnosis, drug or alcohol abuse, economic status, and educational information will be released and/or communicated if indicated below. I further understand that this information might contain information regarding my family.
(Name of Person, Job Title and/or School/Agency/Entity)
Treatment Plans (Please Initial)*
Treatment/Discharge Summary (Please Initial)*
Health/Medical Records (Please Initial)*
Case/Progress/Therapy Notes Academic (Please Initial)*
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.
I understand this authorization will expire one (1) year after the date signed or on the date below, whichever is earlier. *

MonthDayYear
Date
Print Name of Patient/ Parent / Guardian*
Date*

MonthDayYear
Date
CONSENT FORMS
Consent to Treat In Daycare/Preschool Facility or Home (if applicable)

In signing below, I give permission for Integrity Speech Therapy to provide speech and language therapy to my child, in his/her Daycare facility. I also give permission for my child to be seen within the classroom or to be taken to a separate area in order to target specific therapeutic goals. An adequate and acceptable place for the therapist to work with the patient is required. The area must be clean and the floor must be clear of clutter, toys, etc. No smoking is permitted during the session. Animals must be behind closed doors.
Parent/Guardian*
Date*

MonthDayYear
Date
DeclineNot Applicable
Consent to Share Therapy Goals with Classroom Teachers

In signing below, I give permission for Integrity Speech Therapy and therapist to discuss therapeutic techniques and therapy goals regarding my child with his/her classroom teachers. In doing this his/her classroom teachers can reinforce therapy goals within the classroom environment throughout the day.
Parent/Guardian*
Date*

MonthDayYear
Date
DeclineNot Applicable
Consent to Video and/or Audio Tape

In signing below, I give permission for Integrity Speech Therapy to video and/or audiotape for evaluation and therapeutic purposes as well as documentation/tracking progress and will not be shared with anyone else other than those authorized by parent/guardian.
Parent/Guardian*
Date*

MonthDayYear
Date
Decline
Photo/Video Release Form

In signing below, I give permission to Integrity Speech Therapy to have the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of my child, for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium. I hereby release Integrity Speech Therapy and the institutions' legal representatives for all claims and liability relating to said images or videos.
Furthermore, I grant permission to use my statements and audio comments that were given during an interview or guest lecture, with or without my name, for the purpose of advertising and publicity without restriction. I waive my right to any compensation.
Parent/Guardian*
Date*

MonthDayYear
Date
Decline
Mode of Communication with Integrity Speech Therapy
Integrity Speech Therapy may communicate with me/us by the method(s) checked below:

U.S. MailAt HomeTelephoneTextFaxE-Mail (see below)
If you have authorized Integrity Speech Therapy to communicate and correspond with you via email, you acknowledge that Integrity Speech Therapy may transmit personal and confidential information to you regarding your child's treatment by email over the Internet. Integrity Speech Therapy will use reasonable means to protect the security and confidentiality of e-mail information sent and received; however, Integrity Speech Therapy cannot guarantee the privacy and security of such information. It is your duty to protect your email account, password and computer against access by unauthorized people. Integrity Speech Therapy will not be liable in the event that you or anyone else inappropriately uses or accesses your email. You agree that should any information sent to you by Integrity Speech Therapy be intercepted or otherwise accessed or modified by an unauthorized third party, you shall fully release, discharge, and hold harmless Integrity Speech Therapy from any damages arising directly or indirectly from such interception or access. You may revoke your authorization for Integrity Speech Therapy to communicate with you by email at any time by written request.
Name (Print)
Signature

Clear
Date

MonthDayYear
Date
IN-HOME PARENT AGREEMENT
Please check & agree to all:*

Parents and or legal guardians agree to stay on-site in the home during the treatment session.An adult 18 years of age older must be present at all times during the treatment session.Parent involvement as needed during the therapy session will occur.Treatment will be provided in a space in the home clear and free from distractions and use of recreational substances (i.e.,alcohol, cigarettes, and marijuana).Parents must contact the therapist and/or the office for last-minute cancellations in order not to incur a late fee.Family animals/pets should be placed in a separate and secure room from the treatment area during the therapy session.
Parent/ Guardian Signature:*

Clear
Date*

MonthDayYear
Date
ATTENDANCE/CANCELLATION POLICY
Attendance and participation in therapy along with complete compliance with any associated home programs are essential for therapeutic success. While Integrity Speech Therapy understands that illnesses and emergencies occur, we respectfully request that you avoid frequent cancellations or “no shows”. Please adhere to our following policy regarding providing our office with advance notification for any cancellations resulting from vacation, obligations for work family, or any other event.

**All cancellations must be submitted 24 hours prior to your scheduled appointment**
**A fee of $100 may be assessed if the following occurs. This fee will be billed directly to the client and not their health insurance company, as medical insurance does not provide coverage for missed sessions.

• If cancellations are made less than the required 24 hours.

• If the client fails to show up for a scheduled appointment(s).
(Please Initial)*
If you are late for 5 scheduled appointments within a plan of care period (6months), the office will reserve the right to reduce services and/or discharge the client. Additionally, if you arrive late for a scheduled appointment, the session will still end at the scheduled time or may be canceled.
(Please Initial)*
If you fail to appear for an appointment (no-show) without providing the appropriate advance notification for two or more appointments within a plan of care period(6months), the office will reserve the right to cancel all pending appointments and no longer offer services to you as a client.
(Please Initial)*
I, name* , understand the attendance/cancellation policy and the risks of not adhering to it.
Name of Patient*
Relationship to patient*
Health Insurance Waiver Acknowledgement
While all patients sign the Financial Agreement as part of the initial registration documents, the Health Insurance Waiver Acknowledgment must be signed by the responsible party for the following patients:
- Managed Care patients seeking treatment without a referral.
- Patients using the Point of Service options.
- Patients that have exhausted their benefit plan limits.
- Patients that wish to use Auto insurance claims instead of their health insurance.
- Self-Pay patients.
Agreement between Patient and Integrity Speech Therapy
Please select one:

MANAGED CARE - WITHOUT A REFERRAL OR OUT OF NETWORK I understand that my insurance contract with my health insurance plan(s) require a referral authorization from my designated primary care physician for certain medical services and/or requires me to be financially responsible for all or part of my visits. I understand that at this time I have the option to reschedule my appointment and return at a later date with an appropriate referral authorization. I have chosen to be seen by the provider without an appropriate referral or under an "Out of Network" option. Therefore, I agree to be personally responsible for payment of all charges incurred as described by my health insurance plan.POINT OF SERVICE OPTIONS I understand that my health insurance plan(s) provide(s) me with several options. I have chosen to receive services from the provider under one of those options which requires me to pay a higher deductible,co-payment, or coinsurance according to the provisions of that contract.PLAN BENEFIT LIMITS I understand my physician has prescribed a treatment/service that is not covered by my health insurance plan(s)I am that I am financially responsible for all non-covered charges.SELF-PAY I acknowledge that I am a 'Self Pay' patient. Some reasons for my self-pay status may include but are not limited to having a no plan coverage, being seen without a valid referral or prescription script, receiving non-covered services or not having selected a PCP as required by my insurance plan. I understand that as a self-pay patient, I am not automatically eligible for a discount though I may apply for a discount based on family unit income and insurance status.
By signing this form, I am certifying that I agree to be financially responsible for the patient due portion of my account and that I agree to pay an estimate of the amount due at the time services are rendered. If the actual charges exceed the estimate paid, I understand that I will be billed for the difference. Likewise, if the actual charges are less than the estimate paid, I will be entitled to a refund for the amount paid in excess of the actual charges.
Signature of Patient or Responsible Party*

Clear
Date*

MonthDayYear
Date
Acknowledgment That You Have Received Our HIPAA Privacy Notice
Integrity Speech Therapy is required by law to keep your health information and records safe. This information may include:
- Notes from your doctor, teacher or another healthcare provider
- Medical history
- Test results
- Treatment notes
- Insurance information
We are required by law to give you a copy of our privacy notice. This notice tells you how your health information may be used and shared.
Please check any that apply:*

I acknowledge that I have received a copy of Integrity Speech Therapy HIPAA Notice of Privacy Practices that fully explains the uses and disclosures they will make with respect to my individually identifiable health information.I have had the opportunity to read the notice and to have any questions regarding the notice answered to my satisfaction.I understand Integrity Speech Therapy cannot disclose my health information other than as specified in the notice.I understand that Integrity Speech Therapy reserves the right to change the notice and the practices detailed therein if it sends a copy of the revised notice to the address I have provided.
Name of Patient*

First NameLast Name
Date*

MonthDayYear
Date
Signature of Patient or Legal Representative*

Clear
Relationship to Patient*
HIPAA POLICY A NOTICE OF PRIVACY PRACTICES
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. HIPPA provides penalties for covered entities that misuse personal health information. As required by HIPPA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. Treatment means providing, coordinating, or managing health care and related services, by one or more health care providers. An example of this would include a physical examination. Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collections activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment. Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review. We may create and distribute de-identified health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer: The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosure to family members, other relative, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
- The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
- The right to inspect and copy your protected health information.
- The right to amend your protected health information.
- The right to obtain a paper copy of this notice from us upon request.
This notice is effective as of 1/1/2020 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaints with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

Please contact the following for more information:

The U.S. Department of Health & Human Services Office of Civil Rights 200 Independence Avenue, S.W., Washington, D.C. 20201 Phone: (202) 619-0257 or Toll Free: 1-877-696-6775
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MARYLAND PHONE: (301)-337-7893 OAKLAND PHONE: (510)-631-2753 FAX: (855)754-8261 | EMAIL: INFO@INTEGRITYSPEECHTHERAPY.COM

Child History Form

Siblings in the household:

If no, complete below:

Medical History

CONSENT FOR SERVICES

AUTHORIZATION FOR RELEASE AND/OR REQUEST FOR INFORMATION

CONSENT FORMS

Mode of Communication with Integrity Speech Therapy

IN-HOME PARENT AGREEMENT

ATTENDANCE/CANCELLATION POLICY

Health Insurance Waiver Acknowledgement

Agreement between Patient and Integrity Speech Therapy

Acknowledgment That You Have Received Our HIPAA Privacy Notice

HIPAA POLICY A NOTICE OF PRIVACY PRACTICES