Download New Patient Paperwork and Privacy Policy for Building Blocks Pediatrics, LLC and more Summaries Pediatrics in PDF only on Docsity!
Welcome to the Building Blocks Pediatrics, LLC.
Providing comprehensive therapy for your child
The following items MUST be completed, signed, and brought to the first meeting with your therapist:
1. New Patient Paperwork including SIGNED Authorization for the Release of Medical Records ,
SIGNED Acknowledgement of the Receipt of Privacy Policy, SIGNED Consent to Bill and Treat.
2. A PRESCRIPTION from your childâs primary care physician (with diagnosis code) for PT, ST, or OT
Evaluation and Treatment. (This is extremely important so we can bill your insurance provider.)
3. A PHOTOCOPY of your insurance cards and driverâs license or photo ID, front and back. (We can also
make a copy of insurance card and ID in the office)
4. Any prior therapy notes, evaluation and or/or medical information that will assist us in treating your
child.
Please bring all information listed above to your first appointment. Once your first appointment has been
scheduled, the therapist will reserve this time for you and your child. Please call 770-321-6705 as soon as
possible if you will be unable to attend. We canât wait to meet you!
We have 2 convenient locations to serve you in North Atlanta
East Cobb /Surrounding Areas: 1230 Johnson Ferry Place Ste G10 Marietta, Georgia, 30068
FROM DOWNTOWN: Go N on 75 and exit Delk Rd. -go east (right) on Delk Road- it will turn into Terrill Mill and then Lower Roswell (stay straight). Drive East for approximately 10-13 minutes. Make a Left (north) onto Johnson Ferry Road. Make a Right onto Johnson Ferry Place (at light). Make 2nd Right into parking lot (at mailbox) - we are in building G-our suite is G-10.
FROM 120 (Marietta Hwy) and Roswell Road (Hwy 9): Turn on to 120 and go West approximately 4-5 miles, make a left at Johnson Ferry Road (2nd after the Avenues). Make a Left on Johnson Ferry Place (at light) make 2nd right into parking lot (at mailbox)- we are in building G Suite G-
Buckhead/Surrounding Areas: 267 West Wieuca Road NE Ste 101 Atlanta, Georgia 30342
FROM DOWNTOWN: Go North on I75 and I85 toward GA 400 North/Greenville. Merge onto GA 400 North toward Buckhead/Cumming. Take GA 141-Conn Lenox Rd Exit toward Buckhead. Turn slight left to take the GA-141 W ramp toward Piedmont Rd. Merge onto Lenox Road NE/GA-141 Conn West. Turn slight right onto Piedmont Road NE/GA237. Turn Right onto Roswell Road NE/US-19/GA-9. Turn right onto West Wieuca Rd- Our suite is 101 FROM 120 (Marietta HWY) and Roswell Road (Hwy 9 ): Take I 75S/GA 400S toward Atlanta. Take the I-285 Bypass E Exit, toward Greenville/Augusta. Merge onto I-285 E/GA-407 E. Take the US-19 Roswell Rd. Exit toward Sandy Springs. Keep right at the fork to go on Roswell Rd. NE/US-19/GA-9. Turn Left onto West Wieuca Rd. Our Suite is 101
Building Blocks Pediatrics, LLC Summary of Privacy Notice
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US
1230 Johnson Ferry Place, Ste G-10 267 West Wieuca Rd NE, Ste 101
Marietta, GA 30342 Atlanta, GA 30342
Office 770-321-6705 Fax 404-551-
Todayâs Date_________________________
Childâs Name (as it appears on insurance card):_______ __________________________________DOB _____________ Gender M or F
Address ______________________________________________________ City _______________________ State __________ Zip________________
Home Phone Number ______________________________________ Email___________________________________________________________
Person filling out this form: _______Mother_______ Father _______ Stepmother _______ Stepfather________ Other: ____________
Mother Name: ______________________________________________ DOB ___________ Cell Phone ____________________________________
Motherâs Employer _____________________________________________ Work Phone ________________________________________________
Fatherâs Name: ________________________________________________DOB __________ Cell Phone _________________ __________________
Fatherâs Employer _______________________________________________Work Phone ________________________________________________
Marital Status of Parents: _______________________________________Person with whom child resides:___________________________
Primary Physician __________________________________________________Physician Phone _________________________________________
Referring Physician (if different)___________________________________Physician Phone _________________________________________
Diagnosis (if known) __________________________________________________________________________________________________________
Please list all people living in household:
NAME AGE RELATIONSHIP TO CHILD SPEECH/HEARING OR MEDICAL PROBLEM?
Primary Language spoken in the home:
School/Preschool ______________________________________________________________________________________ Grade_________________ Does your child have an IEP or IFSP? â Yes â No Does your child receive services through school? â Yes â No Do we have permission to email you regarding your childâs therapy services and billing/invoicing? â Yes â No
NEW PATIENT INFORMATION FORMPatient information^ Page 1
Does your child have any of the following?:
Socializing Problems â Yes â No Feeding Problems â Yes â No
Sleeping Problems â Yes â No If you checked yes for any of the above, please explain:
Does your child get along with other children? â Yes â No Age of playmates ___________________________________ If no, please explain ___________________________________________________________________________________________________________ How does your child usually let you know their wants/needs? ______________________________________________________________ Does your child communicate well with you/others? â Yes â No If no, please explain _____________________________ Does your child Answer when you to talk to him/her? â Yes â No Talk about what they are doing? â Yes â No Ask for help? â Yes â No What are your childâs interests? (favorite toys/activities/songs) ___________________________________________________________ __
Is your child enrolled in any community activities (music class, play groups, Motherâs Morning Out Program?
Please list your goals for therapy: _____________________________________________________________________________________________
Printed name of Parent/Legal Guardian _______________________________________________________________________________
Signature of Parent/Legal Guardian _______________________________________________________________Date________________
Building Blocks Pediatrics, LLC Developmental Milestones Page 3
BEHAVIOR AGE COMMENTS
Sat up independently Crawled Walked Alone Spoke First Word Put several words together Dressed Self Finger fed self Ate with utensils Became toilet trained
I, ________________________________________ (parent/legal guardian), knowing that _____________________________________________ (childâs name) has a diagnosis requiring Occupational, Speech, or Physical Therapy treatment (OT, ST, PT) voluntarily consent to such care for the aforementioned child by Building Blocks Pediatrics, LLC as may be beneficial in the professional judgment of the childâs the rapist(s) and primary care physician. I am aware that no guarantee has been
made as to the effect of OT, ST, or PT on my child. Parent Initials __________
I hereby authorize Building Blocks Pediatrics, LLC Billing department to bill my insurance company for direct reimbursement of therapy services rendered to my child. Unless otherwise noted, benefit payment will be assigned directly to Building Blocks Pediatrics, LLC. I understand that patient or patientâs family is responsible to pay all fees accrued, regardless of insurance verification or anticipated insurance coverage if insurance refuses to pay provider a portion of the fees or in full. I agree to pay all fees within 30 days after bill has been mailed and understand that if any fees not paid within 30 days will result in a 10% or greater late fee. In the event of a returned or invalid payment, as well as an unpaid balance over 90 days, I agree to pay any and all additional associated banking, legal, and/or collection fees. I understand that I am ultimately responsible for payment of all services received. I understand that I am advised to fully know and understand my insurance benefits prior to my child receiving therapy services. I understand that all insurance plans are different and it is impossible for Building Blocks Pediatrics, LLC to know the specifics of my plan and/or if my plan will reimburse for services received. Regardless of insurance verification or
anticipated insurance coverage, I agree to pay all fees accrued for services received. Parent Initials _________
I am aware that gross motor play is often encouraged during therapy. Use of swinging, running, climbing, and jumping assist with a variety of skills and performance components the therapist may need to address. I consent to use of gross motor play and exempt my child, therapist(s) and employee(s) and owner(s) of Building Blocks Pediatrics, LLC, from
any injury resulting from this type of play. Parent Initials ________
I am aware that Building Blocks Pediatrics, LLC is a teaching and learning facility. Students and other health care professiona ls come to this facility to learn and observe treatments being performed or led by my childâs OT, PT, and/or ST. I give consent for other professionals and students to participate in treatment sessions. I have the right to withdraw
this consent on any day if I choose to do so. Parent Initials _________
Parent/Legal Guardian Printed Name : _______________________________________________________________________________________
Parent/Caregiver/Guardian Signature: __________________________________________________________Date________________________
Building Blocks Pediatrics, LLC Building Blocks Pediatrics, LLC PATIENT SERVICES AGREEMENTInsurance PagePage 44
Permission for Family to Leave Site During Treatment
I understand that while my child receiving therapy, I may leave the premises. However, I agree to leave a
working cell phone number where I can be reached during my absence. In addition, I agree that I will not
travel more than ten miles from the facility and will return at least 5 minutes prior to the end of the my
childâs session. I give consent and permission to Building Blocks Pediatri cs for any additional treatment or
transportation that may be needed in the event my child is injured or needs medical attention. I
understand that failure to comply with the requirements listed above will result in immediate revocation of
this ability. I also understand that the ability to continue to leave the premises while my child is in therapy
is at the discretion of Building Blocks Pediatric Therapy and/or the therapist and may be revoked at any
time.
I hereby release Building Blocks Pediatrics, LLC, and any agents as well as any assignees, from any and all
claims for damages related to my leaving the premises during my childâs therapy.
Childâs Name _______________________________________ ___________ Cell Phone Number ___________________________
Parent/Legal Guardian Printed name____________________________________________________________________________
Parent/Legal Guardian Signature ________________________________________________________________________________
Secondary Emergency contact Name/Phone Number _________________________________________________________
Photograph/Video
Photographs/videos are sometimes used for digital charts and may be used for education and training
purposes (i.e. clinical supervision, conference presentations) and with permission, may be used by Building
Blocks Pediatrics, LLC for marketing purposes. Your childâs name and information is always kept
confidential. I give permission for my child to be photographed/videod by Building Blocks Pediatrics, LLC.
Childâs Name _______________________________________ _____________________________________________________________
Parent/Legal Guardian Printed name____________________________________________________________________________
Parent/Legal Guardian Signature ________________________________________________________________________________
Building Blocks Pediatrics, LLCBuilding Blocks Pediatrics, LLC (^) PermissionsPermissions PagePage 66
At Building Blocks Pediatrics, our greatest desire is to deliver the highest level of care to our patients. To
maximize the benefits of therapy, consistent attendance is critical. Patient commitment to attend therapy
as scheduled leads to better potential for patient progress. Missed and tardy appointments disrupt the
therapistâs schedule, slow your childâs progress, and prevents other children from having the opportunity to
receive services. Therefore Building Blocks Pediatrics asks that you agree to our attendance policy.
By initialing each item listed and signing below, you are indicating that you understand the attendance
policy and the consequences of not keeping your childâs appointments. We anticipate that you will adhere
to the following:
_________ 1. If I need to cancel an appointment, I agree to call at least 24 hours in advance. I understand
that if I call after business hours, I may leave a voicemail with my childâs name, therapy to be cancelled and
reason for cancellation.
_________ 2. I understand that missing an appointment without calling ahead is considered a âno showâ. I
understand that calling within an hour of the appointment is still considered a âno showâ. I understand that
after 2 âno showsâ, my child will be removed from the schedule. I understand that my child will
also be removed from the schedule after 3 cancellations of any kind.
_________ 3. I understand that if I arrive fifteen or more minutes late, I will not be seen that day and it will be
considered a âno showâ.
_________ 4. To avoid a âno showâ, I will refrain from scheduling other appointments around my scheduled
therapy time.
_________ 5. I understand that my referring physician will be notified if I am removed from the schedule due
to inconsistent attendance.
_________ 6. I understand that if my child is seen for 2 or more therapies on the same day and one therapist
has to cancel, I am still responsible for bringing my child to his/her other therapies.
_________ 7. I understand and will follow the treatment plan laid out by the therapists and approved by the
referring physician, at home. The home exercise program is very important key to patient progress.
CHILDâS NAME _______________________________________________________ DOB_________________ _____________
PARENT/LEGAL GUARDIAN PRINTED NAME ___________________________________________________________
PARENT/LEGAL GUARDIAN SIGNATURE __________________________________________DATE________________
Building Blocks Pediatrics, LLC Attendance Agreement Page 7
