Main Form

Part III: Medical History

If your child's medical history includes any of the following, please report the child's age at occurrence, number of occurrences and any other pertinent information. Accidents:

Part IV: Developmental History

At approximately what age did your child do the following?

Part V: Communication Development

6 Part VI: Feeding

Part VII: Motor Development

What hand does your child use for (over 4 year old)

Part VIII: Present Concerns

For children the age of 6 and older:

Pediatrician

Primary Insurance Information

Secondary Insurance Information (If Applicable)

Patient Release

I verify that the information that I have provided is correct. I authorize the release of medical information necessary to process insurance claims to insurance companies and their agencies, for the purpose of filing and payments of medical claims. I also authorize payment of the medical benefits to the provider, Little Tesla Pediatric Therapy, LLC. I acknowledge a fee at the provider's current rate may be charged on all "past due" balances.

EMERGENCY MEDICAL TREATMENT AUTHORIZATION FORM

This form grants temporary authority to a designated adult to provide and arrange for medical care for a minor in the event of an emergency. where the minor is not accompanied by either parents or legal guardians. and it may not be feasible or practical to contact them. This form should accompany the child in the event of off-site trips or emergency relocation of the program.

AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)

I do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for (hereafter "Designated Adult-) to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor. If the injury or illness is life threatening or in need of emergency treatment. I authorize the Designated Adult to summon any and all professional emergency persqnnel to attend. transport, and treat the minor and to issue consent for any X-ray. anesthetic, blood transfusion, medication. or other medical diagnosis. treatment, or hospital care deemed advisable by. and to be rendered under the general supervision of. any licensed physician, surgeon. dentist. hospital. or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care. It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Designated Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel.

Notice of Protected Health Information Privacy Practices Generalized Consent for Treatment

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUR CHILD MAY BE USED AND

DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW CAREFULLY.

When I refer to "you" or "your" below, it represents your child or the patient receiving services from Little Tesla Pediatric Therapy LLC. The initials LT are used to represent Little Tesla Pediatric Therapy LLC.
As part of the healthcare service you receive from Little Tesla Pediatric Therapy, health records are generated and maintained describing your child's care including, but not limited to, your name, address, phone number, social security number, health history, symptoms, examination and test results, diagnoses, procedures, treatments, and plans for future care or treatment. This information is called "Protected Health Information" (PHI). This Notice of Privacy Practices describes how Little Tesla Pediatric Therapy, LLC may use and disclose your information and the rights that you have regarding your health information.

Uses and Disclosures of Health Information Without Authorization
When you obtain services from Little Tesla Pediatric Therapy, LLC, certain uses and disclosures of your health information are necessary and permitted by law in order to treat you, to process payments for your treatment, and to support the operations of the entity and other involved providers. The following categories describe ways that we use or disclose your information, and some representative examples are provided in each category. All of the ways your health information is used or disclosed should fall within one of these categories.
Your health information will be used for treatment: For example: Disclosure of medical information about you may be made to therapists, doctors, nurses, technicians, or others who are involved in treating you. This information may be disclosed to other physicians who are treating you or to other healthcare facilities involved in your care. Information may be shared with pharmacies, laboratories, or radiology centers for the coordination of different treatments.
Your health information will be used for payment: For example: Health information about you may be disclosed so that services provided to you may be billed to an insurance company or a third party for reimbursement of services rendered. Information may be provided to your health plan about treatment you are going to receive in order to obtain prior approval or to determine if your health plan will cover the treatment.
Your health information will be used for health care operations: For example: This information in your health record may be used to evaluate and improve the quality of the care and services we provide.
Disclosures Required by Law or Otherwise Allowed Without Authorization or Notification
The following disclosures of health information may be made according to state and federal law without your written authorization or verbal agreement:

Any other uses or disclosures of your health information not addressed in this Notice or otherwise required by law will be made only with your written authorization. You may revoke such authorization at any time.
Notice of Privacy Practices / Generalized Consent (continued)
⦁ When a disclosure is required by federal, state, or local law, judicial or administrative proceedings, or for law
⦁
enforcement; examples would be reporting gunshot wound or child abuse, or responding to court orders
⦁ For public health purposes, such as reporting information about births, deaths, and various diseases, or disclosures to the FDA regarding adverse events related to food, medications, or devices
⦁ For health oversight activities, such as audits, inspections, or licensure investigations
⦁ To organ procurement organizations for the purpose of tissue donation and transplant
⦁ To avoid a serious threat to the health or safety of a person or the public
⦁ Contacting you to provide appointment reminders or to recommend treatment alternatives
⦁ Notifying you of health-related benefits and services that may be of interest to you
Required Uses and Disclosures: Under the law, we must make disclosures when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with federal privacy law.
Uses and Disclosures Requiring Authorization

Should you ever believe your privacy rights have been violated, we request you to file a complaint with our office by

contacting us at (321) 368-2172 or by e-mail to: littletesla73@gmail.com. You may also register your complaint with
YOUR INDIVIDUAL RIGHTS UNDER HIPAA
You have the right to request restrictions on certain uses and disclosures of your Protected Health Information. For example, you may wish to restrict your employer from knowing about a medical condition. Regardless of your request, please know that the HIPAA rules allow our office to share your Protected Health Information with the Covered Entities. If you wish to restrict your PHI please make this request in writing to LT and discuss with your therapist.
You have the right to receive your Protected Health Information in a confidential communication from our office, such as the US mail. If you have a specific request for communication please discuss this with your therapist or Vesna Candle, LT owner.
You have the right to inspect and copy your Protected Health Information. Copies of your Protected Health Information are available for a reasonable fee paid to our office to cover our expenses of reproducing them. You may request this information at any time via your therapist, the office manager, or Vesna Candic, LT owner.
You have the right to request that we amend your Protected Health Information. In some cases, we may require that these requests be in writing and be supported by a reason for the change. Generally, this will not apply to such routine changes as address or phone number listings.
You have the right to receive, upon request, an accounting of your Protected Health Information that we have provided to Non-Covered entities.
If you have read and responded to this notice through electronic media such as our website or email, you have the right to receive a paper copy of this notice upon request.
If you would like to exercises any of these rights, please contact Little Tesla Pediatric Therapy LLC owner Vesna Candic directly at (321) 368-2172 and we will make any necessary arrangements for you.
Little Tesla Pediatric Therapy LLC .is required by law to maintain the privacy of your Protected Health Information and to provide you with this notice of our legal duties and privacy practices as they apply to your Protected Health Information. We are also required to abide by the terms of this notice, which is currently in effect as of December 15, 2012.
In the future, we reserve the right to change the terms contained in this notice and make any new provisions effective for all of the Protected Health Information we maintain. In the event we elect to change the terms of this notice, a new notice will be posted in our office. In addition, you may receive notification by direct mail, email, or other such communication as our practice may implement from time to time.

Notice of Privacy Practices / Generalized Consent (continued)
the Secretary of the US Department of Health and Human Services, Office of Civil Rights. As part of our commitment to you, we value your privacy and take every precaution in our practice to preserve your right to that privacy. Any complaint you file will be used strictly to improve our operating procedures and in no way will you be retaliated against for filing a complaint.
Should you have any questions or concerns, please contact Little Tesla Pediatric Therapy LLC. Owner Vesna Candic directly at (321)368-2172 to obtain further information.
Generalized Consent for Treatment
I have read and understand the Notice of Protected Health Information Privacy Practices for Little Tesla Pediatric Therapy LLC. I understand that if I do not sign this consent form my child cannot be evaluated or treated by Little Tesla Pediatric Therapy LLC.
When Little Tesla Pediatric Therapy LLC.examines, diagnoses, treats, or refers your child, we will be collecting what the law calls Protected Health Information (PHI) about your child. We need to use this information to decide on what treatment is best for your child, provide treatment to your child, and collect payment. We may also share this information with others who provide treatment to your child or need it to arrange payment for your child's treatment or for other business or government functions.
By signing this form, you are agreeing to let me use your child's Protected Health Information (PHI) for the purposes of payment, treatment, and health care operations. You are also agreeing to allow communications via email, text messages, voice mail and telephone which may contain your child's PHI.

Payment Agreement

Little Tesla Pediatric Therapy, LLC we are committed to providing your child with the utmost in quality rehabilitative services. In order to maintain this level of standard practice, timely payment must be received for services rendered. Payment is expected at the time of service unless other arrangements have been made in advance, or we are attempting to bill your insurance company. Please note that insurance coverage does not guarantee payment for speech-language/occupational therapy services rendered. If your insurance company denies payment for any reason, you will be billed the contracted rate.
For Privately Paying Patients: Payment will be due at the time of service according to our current rate schedule.
For Patients With Jn-Network Insurance and Medicaid:
Proof of insurance is required prior to your first appointment so that we may gather benefit information and obtain prior authorization if required to do so by your carrier.
Any co-pays and/or deductibles are expected at the time of service. This is legally required as per your contract with the insurance company.
We will submit therapy claims on your behalf, but please note this is not a guarantee of payment. If your insurance company denies part, or all, of the therapy claim, you will be billed at the contracted rate for your carrier.
We will make reasonable effort to assist you in collecting payment from your insurance carrier. If your insurance company requires submission of information from you directly, you will be expected to do so in a timely manner. Claims that remain unpaid after 60 days will be billed to you directly.
Your insurance benefit is a contract between you and your insurance company; we are not party to that contract. If you have questions about your insurance benefits, please contact your carrier directly. We will happy to provide you with any necessary procedure and diagnosis codes they may require to answer your questions.
For Patients With Out-of-Network Insurance:
Payment is due at the time of service using our current rate schedule.
We can provide you (upon request) with a receipt/ invoice containing proper coding that you can submit directly to your insurance carrier.
Your insurance benefit is a contract between you and your insurance company: we are not party to that contract. If you have questions about your insurance benefits, please contact your carrier directly.
Non-Payment: Account balances are expected to be paid prior to your next scheduled therapy session unless other payment arrangements have been made with owner. If your account has not been paid in full within IS days, therapy will be put on hold until payment has been made. If your account has not been paid within 30 days, a late charge of $25.00 will be applied to your account balance, and every subsequent 30 days thereafter. In the event that we turn this matter over to a collection agency or to an attorney, all fees and costs incurred will be your responsibility.
No-Show / Missed Appointment Fees: While we strive for regular attendance, we understand that children get sick and situations arise which will result in the need to cancel your appointment. Please do us the courtesy of giving us as much notice as is possible. Sessions cancelled within 2 hours may be subject to a no-call I no-show fee. Sessions missed without notification will be billed the no-call / no-show fee of $25.00. Payment for this fee will be required prior to your next scheduled therapy session.

I read, understand, and agree to comply with the Payment Agreement of Little

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