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  • GETTING STARTED/FAQ
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    • PATIENT APPOINTMENT FORM
    • NEW CLIENT PACKET
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New Client Packet

"*" indicates required fields

Therapy Type*
MM slash DD slash YYYY

DEMOGRAPHIC INFORMATION

MM slash DD slash YYYY
Address*

Parents/Care-givers

Emergency Contact (Other than parents)

Who lives at home and what is their relationship to the child

Insurance Information

MM slash DD slash YYYY
MM slash DD slash YYYY
How did you hear about us?

MEDICAL INFORMATION:

What Equipment does your child have?

CURRENT CONDITION

MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
Is your child currently taking any medications?*
Does your child sleep / nap well?*
Does your child participate in age appropriate movement activities (e.g. riding a bike, skipping )?*
BetterAverageWorse
Get along with brothers/sisters
Get along with other children/friends
Behave with his/her parents
Play and work alone

MEDICAL HISTORY

Provided by*
Prenatal History*

Birth History

Birth Order*
*

DEVELOPMENTAL HISTORY:

MILESTONES
Allergies: (food/medication/environmental)*
Hearing Problems*
Tubes Placed*
Vision Problems*
Feeding Difficulties*
Previous Therapy*

SOCIAL/ EDUCATIONAL HISTORY:

Special Education Class/Program*

FEEDING / ORAL MOTOR HISTORY

Was your child breast fed?*
Was your child bottle fed?*
Does your child demonstrate any of the following difficulties with feeding/oral motor skills skills
Does your child have a history of Reflux?*
Did your child use a pacifier or suck their thumb?*
What does your child drink from currently?
Dependent

Caregiver does majority or all of the task for child

Maximum Assist

parent is helping 75% of the task

Moderate Assist

parent is helping 50% of the task

Minimum Assist

parent is helping 25% of the task

Verbal CuesIndependent
Shirt on/off
Pullover on/off
Pants on/off
Shoes on/off
Jacket on/off
Ties (shoes)
Unties
Zips
Snaps
Unsnaps
Buttons
Unbuttons
Dresses in a timely manner
Toilets Self
Washes Hands
Chews and Swallows
Eats variety of foods
Uses Utensils
Cuts/Spreads
Containers
Brushes Teeth
Bathes/Showers (if >6 years old)

SPEECH AND LANGUAGE CONCERNS

Current Concerns:

*
Is there a family history of speech-language delays/disorders, learning disabilities, or other developmental delay?*

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

I hereby authorize OT Connection to release medical information to my private insurance carrier as is required for determination of benefits and processing of claims. I also authorize payment of medical benefits to OT Connection from my private or government insurance carrier. This authorization is valid for the duration of my child’s treatment from the date signed below. I understand that I may revoke this authorization at any time in writing, but will not hold OT Connection responsible for already releasing information in good faith. OT Connection is released from legal responsibility or liability for the release of the above information to the extent indicated and authorized herein.

I also allow the release of my child’s medical information to the following (physicians and/or additional professionals) indicated:

I understand and consent to the use and disclosure of Health Information by OT Connection for the following purposes:
  • Treatment: This includes the provision, coordination, or supervision of healthcare and related services, including the coordination or management of care and consultation between healthcare professionals related to treatment, or referral to another healthcare professional.
  • Payment for healthcare services provided: This includes actions undertaken by a health plan to decide coverage or the provision of benefits, by Provider or a health plan to obtain or provide compensation for care.
  • Provider's internal operations: This includes quality assessment and improvement activities; reviewing provider performance and training; activities relating to health insurance and benefits; conducting or arranging for medical review, legal services, and audits; business planning and development; and business management and general administrative activities including customer service, resolution of internal grievances, due diligence, and creating de-identified healthcare information.
I understand and agree that:
  • I have the right to request restrictions as to how Health Information may be used or disclosed to carry out treatment, payment, or healthcare operations. I understand and agree that Provider is not required to agree to any restrictions that I may request, but if Provider agrees, it will be bound by that restriction.
  • I have the right to revoke this Consent by notifying OT Connection in writing that I revoke this Consent unless OT Connection has used or disclosed Health Information in reliance on this Consent.
  • OT Connection has the right to disclose relevant Health Information to family member, other relative, close personal friend, or anyone identified by me.
CONSENT FOR CARE AND TREATMENT:As the child’s parent or legal guardian, I hereby grant permission for the licensed therapists at OT Connection to render to my child routine therapeutic care including evaluations, therapeutic activities, educational activities, and other procedures and/or treatments prescribed by my child’s therapist as is necessary in their judgment. I understand that my child is under the care and supervision of my therapist.
TERMINATION POLICY:OTC reserves the right to terminate therapy services at anytime if any staff are subjected to intimidation, harrassment, or any other inappropriate behavior or contact that interferes with the therapy relationship.
ACKNOWLEDGEMENT OF PRIVACY PRACTICES: I acknowledge that OT Connection will use and disclose my personal health information for treatment, payment, and other healthcare operations and as otherwise permitted by law. I understand that I may request a copy of the Notice of Privacy Practices to provide further detailed information about how we use and/or disclose protected medical information about your child for treatment, payment, healthcare operations, and as otherwise allowed by law.

CONSENT FOR PARENT OBSERVATION: I understand that other parents may observe my child in therapy as the parents observe their child in therapy. (This includes the parent education part of each session which is conducted in our shared lobby area unless you request this information to be shared with you and your child privately.)

*

PHOTOGRAPH RELEASE: I hereby authorize OT Connection to photograph and/or video-tape my child for the purposes of treatment, education, and professional reasons (i.e. marketing materials including Facebook, flyers, website, and/or special events).

*
Signature of legal representative of child
MM slash DD slash YYYY
Date

Notice of Financial Responsibility

(Please initial next to each item and sign at the bottom.)
OT Connection will file insurance claims with any insurance carrier, but we do not file to secondary insurance. We are currently in-network with: Aetna, BCBS, Cigna, Humana, Superior Healthcare, Tricare, United Health Care and Medicaid. All parents are expected to know and understand their coverage and benefits for therapy services. Although we verify insurance benefits prior to your first appointment, you may also check your benefits by calling the phone number on your insurance card and speaking with a representative from the insurance company. It is very important that you ask specifically about any “exclusions” or “limitations” to therapy benefits. A quote of benefits from your insurance company is not a guarantee of payment. In the event your insurance chooses not to pay for services for any reason you are ultimately responsible for all charges.
I certify that the insurance information I have provided to OT Connection is accurate, complete, current, and that there is no other insurance coverage primary to this policy. I assign my right to receive payment of authorized benefits to OT Connection. I request that payment of authorized benefits be made on my behalf to OT Connection for any services provided.
Please provide OT Connection with a copy of your insurance card each time you receive a new card and/or your insurance information changes. Please understand that if your insurance company delays payment or is waiting on additional information before they render payment, and the balance due is past 60 days, the balance is your responsibility and is due immediately. If you do not notify us that your insurance has changed then you will be responsible for the balance, and re-filing all retro claims to the correct insurance. Please remember that we require at least 24 hours notice before your appointment if your insurance has changed. If we do not receive this notice then we will require the cash rate deposit for your visit until we can verify eligibility and benefits on the new policy. This applies to COBRA policies as well.
Deductibles, co-insurance and co-payments are due at the time services are rendered. Any portion of the therapy fees not reimbursed by your insurance company is your responsibility. Any balance left unpaid by insurance company after 60 days, is the responsibility of the client. At this time, if payment is not made immediately, services will be placed on hold until the balance is paid in full.
We do our best to answer any insurance related questions, however, calling your insurance company directly is frequently required. Any follow-up regarding non-payment after our initial appeals process is your responsibility. If payment is not issued by the insurance company within 60 days of initial filing, you are responsible for payment in full for all services rendered. It is then your responsibility to follow up with the insurance company regarding any further appeals.
Insurance companies frequently request your medical records for review. The insurance company then puts your claims on hold for review. Due to the frequency of these requests, and the time it takes insurance to complete this process, you will have the option of continuing therapy at the contracted rate we have with your insurance or discontinuing services until the claims have finalized for payment. If you choose to pay for sessions during this process, and your insurance makes payment then we will reimburse you for those payments minus any patient portion. All billing/statement questions should be addressed with Cyndy Winn, our office/billing manager at [email protected] or at 512-251-3230" or 512-251-3230.
Most insurance policies have a visit limitation. Once this limit has been reached your benefits have been exhausted, and insurance will deny all additional sessions. At that time you may choose to continue therapy at our fee for service rate. You are responsible for tracking your visit limit. OT Connection is not responsible for tracking or notifying you when this limit has been reached. Any sessions denied for exceeding your visit limit will be the financial responsibility of the guarantor on your child’s account.
Insurance companies use procedure codes to process your claim. These codes are billed in units. Some insurance companies have limits on the number of units they will pay per visit/per day. The initial evaluation and the re-evaluation may exceed the number of units allowed through some insurance plans. It is the client’s responsibility to pay for any portion of the evaluation or re-evaluation not reimbursed by the insurance company.
You are responsible for payment of any no-show or short notice cancellations. These are not billable to insurance. Please see the cancellation charges section on our fee schedule for specific details.
In the event that a check is returned for insufficient funds, there will be a fee of $35.00 due on your account in addition to the original balance.
All accounts turned over to our outside collection agency will incur an additional charge of 33% on your balance for administrative fees. (This is the amount charged to OT Connection by the Collection Agency.)

GENERAL GUIDELINES

The following information is a list of general guidelines that will assist in creating a treatment environment that is as efficient and smooth as possible. If you have any questions, please speak with your therapist.
  1. Please arrive a few minutes early and have your child dressed in comfortable clothing that may get dirty during therapy.
  2. We encourage parents to attend their child’s session as long as your child’s therapy is not interrupted and they are able to make progress. Please advise your therapist if you would like to attend your child’s session in advance. Due to the HIPAA privacy laws there is a specific procedure that must be followed to ensure the privacy of other clients in our therapeutic setting.
  3. The last few minutes of your child’s session will be used to discuss your child’s progress in therapy and review any home activities the therapist recommends. Please keep in mind our therapists have very tight schedules with patients scheduled at the top of every hour so we ask that you are respectful of their time by bringing your discussions to an end by the top of the hour. If you have additional questions or would like to discuss your child’s progress further, please leave a message for the therapist, and they will be more than happy to discuss at your child’s next therapy session. If you feel you need a significant amount of time to talk to your child’s therapist, you may schedule a consultation appointment with your therapist. The charge for this appointment is $50.00/30 minutes. This fee is due from you at the time of the appointment and will not be billed to insurance. This appointment is also subject to our cancellation policy.
  4. For your convenience, OT Connection allows parents/legal guardians or caregiver to leave the clinic during their child’s appointment. However, you are required to return and come into our clinic 15 minutes before your child’s appointment is scheduled to end so the therapist can discuss treatment with you. If tardiness becomes a recurring issue, we will require the parent/legal guardian or caregiver to stay in the clinic during the patient’s treatment for all future sessions.
**OT Connection must have a cell phone number to reach you before you leave the clinic. **
THERAPY ATTENDANCE EXPECTANCE

We value your child’s progress in therapy and consistent attendance equals consistent progress!

Please initial next to each item and sign at the bottom.

If you must cancel an appointment, please do so by giving 24 hours notice. We do encourage rescheduling your appointment if possible. It is essential to keep a regular schedule for any treatment to be successful. Please note that if we receive less than 24 hours notice there will be a $50 short notice cancellation fee applied to your account. These charges are not reimbursable by your insurance company and must be paid at the time of your next scheduled therapy appointment.
If you must cancel or reschedule an appointment please contact the Front Desk, [email protected] or by phone: 512-251-3230. Voicemails may be left 24 hours a day. (Please notify the front desk of any cancellations, notifying your therapist and not the front desk will still result in a $50.00 no-show fee.) All emails and voicemails will be returned to confirm the cancellation. If you do not receive a confirmation from the front office, your appointment has not been cancelled and you will be charged the $50.00 no-show fee.
If you must cancel or reschedule an appointment please contact the Front Desk, [email protected] or by phone: 512-251-3230. Voicemails may be left 24 hours a day. (Please notify the front desk of any cancellations, notifying your therapist and not the front desk will still result in a $50.00 no-show fee.) All emails and voicemails will be returned to confirm the cancellation. If you do not receive a confirmation from the front office, your appointment has not been cancelled and you will be charged the $50.00 no-show fee.
If you do not show up or “NO-SHOW” for your appointment and do not give notice, you will be charged a fee of $50.00.
If you do not show up or “NO-SHOW” for your appointment and do not give notice, you will be charged a fee of $50.00.
Prompt, regular attendance is key to a successful outcome for your child’s therapy. Be advised that if you arrive to your appointment 10 minutes or more late, your appointment time for that day will need to be re-scheduled and there will be a $50.00 fee for this missed appointment. These charges are not reimbursable by your insurance company and must be paid at the time of your next scheduled therapy appointment.
Two “no show “ cancellations, missing more than 20% of the scheduled treatment sessions, or habitual cancellations and or showing up late will result in the loss of a reserved treatment time slot and/or your child being discharged from therapy.
You will be notified as far in advance as possible when your therapist is ill, on vacation or attending a continuing education conference. Every effort will be made to reschedule your appointments so that your child will miss as little treatment as possible. Alternate therapists will provide care due to your primary therapist’s absence when available. If your child is scheduled to see more than one therapist on the same day you will be expected to attend those sessions in order to comply with the attendance expectancy policy.
Signed, and Printed Name of Legal Representative of Patient
MM slash DD slash YYYY
Date

OT CONNECTION ALLERGY WAIVER

On occasion we use snacks as part of your child’s therapy session.

(Please Initial and Sign Below)

*
We are committed to providing a safe atmosphere for our patients so PLEASE LIST ALL OF YOUR CHILD’S KNOWN ALLERGIES BELOW.
has NO KNOWN ALLERGIES.
Parent/Guardian Name (Print)
HAS the following KNOWN ALLERGIES or restrictions:
Please list specific foods such as gold fish, candy, gluten free…etc, that you DON’T want your child to consume based on allergies or diet restrictions.
Please list any additional allergies you feel we should be aware of such as medications, latex, specific dyes, etc.
Patient Name
Parent/Guardian Signature
MM slash DD slash YYYY
Date

Authorization for Emergency Care to Minor

In case of emergency, illness or accident the child is given first-aid and the parents are notified. If the parents or the child's doctor cannot be located, the child will be taken to the Emergency Room of your choice.

OT Connection does not assume responsibility for the payment of hospital, doctor or ambulance fees.

I/We the undersigned, parent(s) or legal guardian of the minor listed below:

do hereby authorize any administration of emergency medication by OT Connection. All other services such as; x-ray examination, anesthetic, dental, medical or surgical diagnosis or treatment by any physician or dentist licensed by the State and hospital service that may be rendered to said minor under the general, specific, or special consent of an acting agent of OT Connection, the temporary Custodian of the minor, whether such diagnosis or treatment is rendered at the office of the physician or dentist, or at a hospital licensed by the State. I/We authorize the physician or dentist to call in any necessary consultants, in his/their own discretion. We further authorize said physician or dentist to exercise his /their discretion in authorizing the disposal of any severed tissues or member. It is understood that this consent is given in advance of any specific diagnosis or treatment being required, but is given to encourage those persons who have temporary custody of the minor and said physician or dentist to exercise his/their best judgment as to the requirements of such diagnosis or medical or dental or surgical treatment. This consent shall remain effective for the duration of the patient’s treatment at OT Connection unless sooner revoked in writing, delivered to said physician or dentist of the said Persons entrusted with the custody, care and control of said minor children.
Parent/Guardian Signature
MM slash DD slash YYYY
Date
MM slash DD slash YYYY
Date

Authorization to Release Protected Health Information

***Please list all designated parents and caregivers that will be bringing/ picking your child up from therapy so that we can provide them with the parent education portion of your child’s session. You must list all family members including, but not limited to both parents names if you consent to the release of your child’s information by OT Connection. We will only discuss your child’s session/progress/concerns and accept scheduling changes or billing requests with/from the authorized persons listed below. )***

MM slash DD slash YYYY
Parent/Guardian Signature
MM slash DD slash YYYY
Date
Signing in the capacity of*

I authorize OT Connection and its agents to disclose information related to my child’s care to the following persons upon request:

Patient or Authorized Representative Signature
MM slash DD slash YYYY
Date

OT CONNECTION EMAIL CONSENT FORM

I,
, authorize OT Connection to utilize e-mail as a means of communication to me at the following e-mail address:
(You may list up to 2 addresses) By signing this authorization, I understand the following information regarding e-mailing protected health information:
Privacy Issues

  • I am aware of who else may intercept my e-mail (i.e. other family members, co-workers, etc.) and will be careful about leaving programs operational and/or documents visible/accessible when unattended.
  • I have taken all precautions to eliminate others from accessing my e-mail, even during my absence. I will not hold OT Connection liable for others accessing my e-mail sent by OT Connection
  • It is my responsibility to protect the security of my passwords utilized to access my above stated e-mail address.
  • I hold harmless OT Connection for information loss due to technical failures, such as system crashes, power outages, and overloads at the ISP level.
  • The message (e-mail, including replies and confirmation receipts) will be included as a part of my medical records.
  • Upon notification that an e-mail containing phi was miss-directed, a notation to that effect will be written on a hard-copy of the e-mail and placed in the patient’s medical record. The recipient of the miss-directed e-mail will be asked to delete and destroy the e-mail that was sent in error.
  • OT Connection will not forward patient-identifiable information to a third party without my express written authorization (except for treatment, payment, and health-care operations).
  • OT Connection will not use my e-mail address for marketing purposes and will not share my e-mail address with anyone, including family members.
Entity Authentication

  • OT Connection will save my e-mail address in their e-mail system and utilize this stored e-mail address when e-mailing me.
  • I will be asked to include my legal name and date of birth along with my child’s legal name, and date of birth in the body of messages I send to OT Connection so that medical records are easily retrievable.
ORGANIZATION > Response to E-mail Requests

  • Each outside e-mail that is received by OT Connection is triaged by appropriate authorized personnel throughout the day.
  • Patients, guardians, or authorized personal representatives who e-mail OT Connection will be responded to via e-mail within 2 business days only if there is an e-mail authorization to do so. If more information is required to complete the request, this will be noted in the initial e-mail with a projected response date.
  • OT Connection will utilize the “Reply” option when responding to e-mail requests to ensure that the response goes to the individual who initiated the communication.
  • Out-of-the office replies are activated in the event that an e-mail address will not be serviced by staff or covering providers during an absence that exceeds 2 business days. The out-of-office reply will include the estimated date of return and instructions on whom to contact for immediate assistance.
  • If there is not a signed e-mail authorization, the individual will be contacted by OT Connection via telephone.
I have had an opportunity to review and understand the content of this authorization form. By signing this authorization, I am confirming that it accurately reflects my wishes. I may revoke this authorization at any time by providing my written revocation.
Name of Patient
MM slash DD slash YYYY
Birth Date
Signature of Parent or Legal Guardian
MM slash DD slash YYYY
Date
Printed Name of Parent or Legal Guardian
Relationship to the Patient

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2415 W Pecan Street,
Suite 100
Pflugerville, TX 78660

Fax: 512-251-8760
Phone: 512-251-3230
[email protected]

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