IDENTIFYING INFORMATION
Other family members living in the home
MEDICAL INFORMATION
Please identify all those that apply
ILLNESS / CONDITION
Allergies Seasonal Food
Gastrostomy-Tube
Vision Issues
Asthma / Lung Disease / BPD
Tracheostomy
Gross Motor Issues
Chronic Sinusitis/Colds
Gastrointestinal Issues/Reflux
Fine Motor Issues
Ear Infections
Kidney Diseases
Dental problems
Hearing Loss
Prematurity
Torticollis
Swallowing Problems
Seizures
Feeding Issues
Neurological Issues
Other:
Current Medications
BIRTH / DEVELOPMENTAL / FAMILY HISTORY
weeks
C-Section
MILESTONE
MONTHS / YEARS
EMERGING
NOTYET EVIDENT
Family History of:
EDUCATIONAL HISTORY
THERAPY HISTORY
Has your child currently or ever received therapy?
THERAPY
DATES
PROVIDER
AUTHORIZATIONS
CONSENT FOR TREATMENT
Permission is hereby granted for therapists, clinical fellows, therapy assistants, employees or
contractors of TheraKids Plus, Inc. (collectively, the “Provider”) to render the patient named
above such medical and/or therapeutic treatment as is deemed necessary and according to the
Plan of Care. If enrolled in Telepractice (TeleHealth), permission is hereby granted to providers
to render services. Therakids Plus, Inc. will use a HIPAA compliant platform for service
delivery.
FINANCIAL AGREEMENT: (Please initial as applicable)
I request my insurance carrier to pay to
TheraKids Plus, Inc. all benefits due me related to my pending claim for medical and therapy
services. I agree to pay all applicable deductible and coinsurance amounts due and other fees
for services rendered for which my insurance plan is not liable for payment to the Provider, and
agree to pay the costs of collection including reasonable attorney fees in the event of legal
action to collect such amounts.
I have been notified that TheraKids Plus, Inc. does not have a
contract to participate with my insurance plan or HMO and the requested services have not been
authorized by my insurance plan/HMO, as applicable. I am requesting therapy services as a fee
for service, self-paying patient. I will be responsible for all charges incurred as a result of this
and future visits, including all therapy services, consultations, and evaluations. I also agree to
pay the costs of collection including reasonable attorney fees in the event of legal action to
collect this amount.
I request my insurance carrier to pay to TheraKids
Plus, Inc. all benefits due me related to my pending claim for medical and therapy services. I
agree to notify TheraKids Plus, Inc. immediately in the event I lose or change my insurance
coverage. I will not be responsible for a deductible or co-insurance for services rendered.
CANCELLATION POLICY:
I have been informed of the cancellation policy that states there is a 25.00 fee for patients that
do not show up for their appointment or fail to cancel within 24 hours prior to the appointment.
This policy is to ensure that we are able to continue being convenient to all of our patients.
Situations out of our control do occur and will be considered on an individual basis. This fee
will not be charged if the cancelled appointment is made up in the same week. I also
understand that three “no-show/no call” occurrences will result in my child being placed on
hold until the situation is resolved. (THIS POLICY DOES NOT APPLY TO EARLY STEPS
PATIENTS)
FUNDING INFORMATON
MEDICAID
CHILDRENS MEDICAL SERVICES (CMS)
Florida Healthy Kids
PRIVATE INSURANCE
TRICARE
MEDWAIVER
EARLY STEPS
GARDINER/PLSA SCHOLARSHIP (Step Up For Students)
PRIVATE PAY
AKNOWLEDGEMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICES
I have received and reviewed Therakids Plus, Inc.’s Notice of Privacy Practices, which explains how my or my
child’s medical information will be protected, used and disclosed. I understand that I am entitled to receive a
copy of this document upon request.
TELEPHONE MESSAGES / PRIVACY
When Therakids Plus, Inc. needs to leave a message regarding my or my child’s appointments, financial issues,
and medical information. I prefer to have the information delivered via:
When my therapist picks up or returns my child from a therapy session, he/she may report progress or concerns
in the waiting room area. Other parents/staff may be present.
MEDICAL RELEASE
AUTHORIZATION TO REQUEST & RELEASE OF INFORMATION
Therakids Plus, Inc. (through its employees or other contracted agents) are requesting and/or disclosing
the above patient’s medical record account to or from:
Medicaid Funding Practices
I have been made aware that my child’s Medicaid MMA may operate under a
“Case Rate Model”. This means that my child is assigned a level of impairment and
will be funded based on that impairment.
Level 1: Evaluation Only
Level 2: Mild Impairment – Funding covers approximately 5 (30 minute) visits every 2 months
Level 3: Moderate Impairment – Funding covers approximately 8 (30 minute) visits every 2
months
Level 3: Severe Impairment – Funding covers approximately 11 (30 minute) visits every 2
months’
Level 4: Profound Impairment – Funding covers approximately 16 (30 minute) visits every 2
months.
Frequency or duration of visits may change based on funding available. For
example, if you miss visits, we may be adding visits to future weeks. It is important
that you use your available funding each Plan of Care Period (6 months).
Consent to Participate in a Telepractice (Telehealth) with Therakids Plus, Inc.
1. I understand that, due to COVID-19 mandates, speech/occupational/physical therapy and/or
early intervention services may be provided via Telepractice sessions, evaluations or
consultations. This means that my therapists or early interventionist and I, or a designee will,
through an interactive audio/video connection, be able to consult with my or my child’s
therapist/ITDS.
2. My health care provider has explained to me how the video conferencing technology will be
used. I also understand that my therapist(s)/ITDS will be using HIPAA compliant technology and,
at no time, will my session be shared knowingly with others (unless authorized by the patient or
caregiver). I understand that at times a supervising therapist may join in my session.
3. I understand that Telepractice will not be the same as an “in-person” visit since I will not be in
the same room as the therapist/ITDS, and that some parts of a session, evaluation, or
consultation may be conducted by individuals present with me, or my designee, at the direction
of the consulting therapist/ITDS. Sessions may include activities such as, assessment, treatment
programs, printing of delivered documentation, planning for next session, etc…
4. I understand there are possible risks of an incomplete or ineffective consultation because of the
technology, and that if any of the risks occur, the consultation may terminate. The risks may
include failure, interruption or disconnection of the audio/video connection; a picture that is not
clear enough to meet the needs of the consultation; and a minor risk of access to the
consultation through the interactive connection by electronic tampering
5. I understand that in place of this Telepractice session I may seek face-to-face therapy or
consultation with a therapist/ITDS, if circumstances permit (i.e., COVID-19 mandates).
6. I have read and understand this consent and all of my questions have been answered to my
satisfaction. I understand the mandate for Telepractice services secondary to COVID-19, the
differences between in-person and Telepractice sessions, my responsibilities regarding the
process, the benefits of on-going telemedicine consultation/therapy, and consent to it.
