Pinnacle Pediatric Therapy Group

6215 Lorraine Rd | Lakewood Ranch | FL 34202 Phone: (941)758-4707 Fax: (941)755-3735

Dear Parent,

Thank you for expressing an interest in the Pinnacle Pediatric Therapy of Lakewood Ranch for

your child’s treatment. Your child’s development and therapeutic goals are very important to us.

Please take the time to read and complete the attached intake packet. This information will be

helpful to us in getting to know your child and will also ensure that we have appropriate contact

and billing information. Communication and continuity of care is important to us. Please

provide us with a copy of your child’s most recent evaluation from a speech therapist,

occupational therapist, and/or behavior analyst. An evaluation is required to determine your

child’s needs and to begin treatment. If an evaluation cannot be provided, we will discuss the

evaluation process and related fees with you.

If you will be seeking insurance coverage for services, please send a copy of your insurance card

(front and back) and contact your insurance company to inquire about coverage and any

applicable co-payments. Services cannot be initiated without these documents.

Please return the following to the therapist or the address listed:

Patient Registration and New Client Intake Form

Completed Client/ Parent Questionnaire

Copy of most recent evaluations

Prescription from your child’s Primary Care Physician with a diagnosis and

recommended services*

Copy of both sides of insurance card*

* (if you will be seeking insurance coverage for services)

Thank you for taking the time to review this packet. We look forward to working with you and your

child. Your cooperation in completing every item on the intake packet, including signatures and

person(s) with whom information about your child’s treatment may be shared is appreciated.

If you have any questions regarding therapy services, scheduling, or billing, please feel free to

contact us at 941-758-4707.

Thank you,

Pinnacle Pediatric Therapy of Lakewood Ranch Staff

PATIENT REGISTRATION FORM

Medical Reimbursement Consultants Confidential MRC - 1133 Rev 6.2010

Today’s Date__________ Practice Name: __________________________________

_________________________________ ____ __________ M__F__ __________________ Patient Last Name First Name MI Date of Birth Sex SS#

___________________________ ______________ ____ _______ ____________________ Street Address City ST Zip Home Telephone

_______________________________________________________ ____________________ Mailing Address (if different from street address) Alternate Telephone

Legal / Financially Responsible Party

____________________________________ ___________ M__F__ _________________ Last Name First Name MI Date of Birth Sex SS#

__________________________________________________________ _________________ Street Address City ST Zip Home Telephone

________________________ _________________________________ _________________ Employer Name Address Work Telephone

_____________________________ Email

Insurance Information Primary Insurance Secondary Insurance

Subscriber Name_____________________ Subscriber Name_______________________

DOB ________ SS#_________________ DOB _________ SS# ___________________

Ins. Company________________________ Ins. Company__________________________

Claim Address_______________________ Claim Address_________________________

__________________________________ _____________________________________

ID / Contract#_______________________ ID / Contract#_________________________

Group #_____________ Group#_____________

PCP _______________________ (if listed) PCP ________________________ (if listed)

If pre-certification is required, please list the telephone number specified on your insurance card.

______________________ _____________________

Emergency Contact

Name___________________________ Telephone ______________Relationship____________

Address_______________________________________________________________________

Do we have your authorization to contact this person concerning your medical services if the

need arises? ____yes ____ no _____ initial (patient or responsible party)

Consent and Release I hereby consent to treatment by, and authorize insurance benefits to be paid directly to _______________________

____________________. I agree that I am responsible to pay 1) for services not covered by my insurance

company, 2) co-payments and deductibles, and 3) any expense associated with the collection of a debt owed to them

by me (i.e. Attorney fee, court cost or collection agency fee). I also consent to the release of pertinent medical

information to my insurance carrier(s) for the purpose of processing health care claims.

x____________________________________ ___________ x______________________________ (Signature of Responsible Party) (Date) (Witness)

Office Use Only: Received by ______ Date ______ Patient Reservation Form Completed ______

6215 Lorraine Rd | Lakewood Ranch | FL 34202 Phone: (941)758-4707 Fax: (941)755-3735

Revised 1-2021

New Client Intake Form

I am interested in the following services for my child: (check all that apply)

Speech and Language Services: _______ Evaluation _______ Therapy Services

Occupational Therapy Services: _______ Evaluation _______ Therapy Services

Social-Behavioral Services: _______ Evaluation _______ Therapy Services

Tutoring Services: _______ Assessment _______ Therapy Services

Child’s Full Name ________________________________________________________

DOB ______________________ Gender M or F (Circle One) Age________________

Child lives with: __________________________________________________________

Mother’s Name___________________________________________________________

Address ________________________________________________________________

City _______________________________ State ___________ Zip ________________

Home Phone _________________ Work _________________ Cell _________________

Email _____________________________ Occupation__________________________

Father’s Name____________________________________________________________

Address _____________________________________________ Zip ________________

Home Phone _________________ Work _________________ Cell _________________

Email _____________________________ Occupation _________________________

Siblings? ___yes ___no Ages? __________________________________________

School/Daycare _____________________________________________ Grade _______

Pediatrician _________________________________ Phone: _____________________

Has your child received any diagnosis (Please specify): __________________________

List secondary (Axis II) diagnoses: __________________________________________

Who was the diagnosing physician? _________________________Phone:___________

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Please list any medical conditions: ___________________________________________

________________________________________________________________________

Please list any medications and dosage that your child is taking: ____________________

________________________________________________________________________

Prescribing physician:___________________________ Phone: ____________________

Does your child have allergies? Please list: ____________________________________

________________________________________________________________________

Does your child have funding through: ____Early Steps ____Medicaid ____TriCare

Private Insurance Carrier: __________________________________________________

Policy Number: ___________________________ Group Number: _________________

Does your child currently receive any of the following interventions?

____Speech therapy Provider: __________________________________

____Occupational therapy Provider: __________________________________

____Physical Therapy Provider: __________________________________

____ Applied Behavior Analysis Provider: __________________________________

____ Developmental Services Provider: __________________________________

____Biomedical Provider: __________________________________

____Dietary Specify: __________________________________

Other: __________________________________________________________________

Other important information:________________________________________________

_______________________________________________________________________

_______________________________________________________________________

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Please be advised that an evaluation is required prior to treatment, unless an acceptable

and recent (within 6 months) evaluation is provided by a licensed Therapist, and/or

Behavior Analyst. The fee for the evaluation is based on the time it takes for the therapist

to evaluate and develop a written report and treatment plan. If you wish to bill your

insurance company, a prescription from your pediatrician is needed prior to setting up an

appointment for an evaluation. Although a prescription is not required by law, most

insurance companies required it before processing or paying out the claim.

Please check appropriate statement below and circle any services needed

____ I want my child to receive an eval for the following service(s): Speech OT ABA

____ I will be submitting a recent eval from the following service(s): Speech OT ABA

*An evaluation is not required for tutoring services and social-behavioral services not

seeking insurance coverage, an assessment will be completed if necessary.

I have read and fully understand the above statement.

___________________________________ _______________________

Parent/Legal Guardian Signature Date

CONSENT FOR TREATMENT

I hereby authorize Pinnacle Pediatric Therapy of Lakewood Ranch to evaluate and/or

provide therapy to my child.

__________________________________ ________________________

Signature of Legal Guardian Date

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize Pinnacle Pediatric Therapy of Lakewood Ranch to obtain information

from and release information to the following individuals and organizations: (info about

your child’s treatment will only be shared with those listed; include other

parent/guardians that do not sign below.)

___________________________________ ___________________________________

___________________________________ ___________________________________

Parent/Guardian Signature Date Parent/Guardian Signature Date

I hereby authorize Pinnacle Pediatric Therapy of Lakewood Ranch to release information

to my child’s current school upon request.

___________________________________ _______________________


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ATTENDANCE AND SCHEDULING POLICY

1. I understand that a treatment session consists of 50 minutes of direct treatment. An

additional 10 minutes is used for parent consultation, set-up, clean-up and transitions into

and out of the treatment. ________(initials)

2. I understand that in order to receive the maximum benefit from treatment, it is

important for treatment to occur at the treatment frequency determined between the

therapist and family. I understand that notification of vacation or family obligation is

requested at least two weeks prior to the expected absence, to facilitate rescheduling our

appointment. I understand that we may schedule make-up sessions for vacation times, if

there are times available. _______(initials)

3. I understand that for sessions cancelled with less than 48 hours notice (unless the child

becomes ill in the morning); a cancellation fee of $50.00 will be charged and is billed

directly to me. I understand that if sessions are cancelled with more than 48 hours notice,

I will not be charged a cancellation fee; however, this clinic encourages scheduling a

make up for these and all other sessions in order to ensure optimal progress.

_______(initials)

4. I understand that if we do not cancel and do not keep a scheduled appointment{NO

SHOW}, we will be charged a NO SHOW fee of $50.00. I also understand that three no

shows will result in the termination of our treatment slot. _______(initials)

5. I understand that if my child was not well enough to attend school on the day of his/her

appointment that I should not bring him/her to the scheduled therapy session that day. I

also understand that if my child attends therapy, and then comes down with an infectious

illness or condition such as strep throat, conjunctivitis, chicken pox, lice, etc. I should

notify the clinic immediately so that other children in the area that day can be notified.

________(initials)

PAYMENT POLICY

1. I understand that the clinic cannot wait for payment and that my co-payments or

private payment is due no later than 14 days from receipt of invoice. All checks are to be

made payable to Pinnacle Pediatric Therapy of Lakewood Ranch. Payment may be

mailed or delivered to the office. _______(initials)

2. lf my account becomes overdue by 30 days, I understand that Pinnacle Pediatric

Therapy of Lakewood Ranch will discontinue therapy until payment is made.

_______(initials)

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3. I understand that this clinic may bill my insurance companies directly at my request

only when all of the proper insurance information is on record in the office. It is my

responsibility to contact my insurance plan to find out exactly what is required for direct

billing. _______(initials)

4. I understand that my amounts not covered by my insurance, including deductibles,

coinsurance, non-reimbursable items (such as reports, consultation, and travel) must be

paid by the due date or treatment will be discontinued. I also understand that submission

of claims to the insurance company does not guarantee payment and that I will be held

responsible for all amounts billed. _______(initials)

5. I understand that pertinent medical information will be submitted by this clinic to my

insurance carrier(s) for the purpose of processing health care claims. _______(initials)

6. I understand that if a claim submitted directly by this clinic to my insurance company

is not paid within 60 days of submission, the balance becomes due immediately from me.

The clinic will assist in obtaining insurance coverage by writing reports and letters to

insurance companies. ______(initials)

7. I understand the need to provide notification of outside meetings or consultations at

least three weeks in advance to allow the therapist(s) to prepare and to coordinate

meeting dates and times. I understand that if I want my therapist to attend an outside

meeting (lEP, TEAM meeting, etc.) I will be billed the hourly consult rate plus travel

time to and from the appointment. _______(initials)

8. I have read the above information and understand that, as a client, parent, or guardian,

I am ultimately responsible for payment of all services provided by Pinnacle Pediatric

Therapy of Lakewood Ranch. In the event that my insurance company or other source of

payment decreases or discontinues payment for services for any reason, I will be

responsible for assuming payment for past, current, and future services. ______(initials)

TEACHING AND RESEARCH ACTIVITIES

1. I recognize that this clinic is a professional development site for Universities and

professional organizations. I give permission for therapy student interns to observe my

child's therapy. I understand I will be notified prior to each observation. ______(initials)

2. I understand the clinic conducts multidisciplinary team reviews to ensure consistency

and discuss techniques to increase therapeutic outcomes for our clients. I give permission

for multidisciplinary case reviews of my child’s therapy. ______(initials)

3. I give permission for photographs/videotapes to be taken of my child for educational

and professional development training purposes. ______(initials)

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HIPAA CONSENT TO USE DISCLOSURE INFORMATION

FOR TREATMENT AND HEALTH CARE INFORMATION

Federal regulations from the Health Insurance Portability and Accountability Act

(HIPAA) allow us to use or disclose Protected Health Information (PHI) from your

records in order to provide treatment to you, and for other professional activities (known

as “health care operations”). Nevertheless, we ask your consent in order to make this

permission explicit. The Notice of Privacy Practices describes these disclosures in more

detail. You have the right to review the Notice of Privacy Practices before signing this

consent. We reserve the right to revise our Notice of Privacy Practices at any time. If we

do so, the revised Notice will be posted in our office. You may ask for a printed copy of

our Notice at any time. You may ask us to restrict the use and disclosure of certain

information in your records that otherwise would be disclosed for treatment, or health

care operations; however, we do not have to agree to these restrictions. If we do agree

to a restriction, that agreement is binding. You may revoke this consent at any time by

giving written notification. Such revocation will not affect any action taken in reliance on

the consent prior to revocation. This consent is voluntary; you may refuse to sign it.

However, we are permitted to refuse to provide health care services if this consent is

not granted, or if the consent is later revoked.

I hereby consent to the use or disclosure of my Protected Health Information as

specified above:

Patient Name:__________________________________________________________

___________________________________ _______________________


CLIENT’S RIGHTS AND RESPONSIBILITIES

I have read my Rights and Responsibilities and fully understand the information

contained therein.

__________________________________ _________________________


I, the undersigned, certify that I (or my dependent) have insurance coverage with

_____________________________________________ and assign all insurance benefits

(if applicable) directly to Pinnacle Pediatric Therapy of Lakewood Ranch.

Please complete and send the Client Registration/Intake Form & Client Questionnaire to

Pinnacle Pediatric Therapyof Lakewood Ranch:

6215 Lorraine Rd. Bradenton, FL 34202

7

Pinnacle Pediatric Therapy of LWR Client

Rights & Responsibilities As a client of Pinnacle

Pediatric Therapy of

Lakewood Ranch, or as a

family member or guardian of a client, we want you to know that we are committed to honoring your rights. By taking an active role in your therapy, you can help your providers to meet your needs. You have the right to receive treatment without discrimination due to age, sex, race, or gender. Rights You have the right to: • Receive information in a way that you understand. • Receive information about your current treatment plan, out-comes, and recommendations. • Be informed about proposed treatment options including the risks and benefits, other options, what could happen without treatment, and the outcomes of treatment. • Be involved in all aspects of treatment and take part in decisions about treatment. • Expect the provider to get your permission before taking photos, recording, or filming you/your child for the purpose of training, education, or media. • Decide to take part in research or clinical trials related to treatment. Your participation is voluntary, and written permission must be obtained from you before you participate.

• A decision to not take part in research or clinical trials will not affect your right to receive treatment. • Receive kind, respectful, safe, quality care delivered by skilled professionals. • Know the names and credentials of providers who are treating you. • Receive efficient and quality care with high professional standards that are continually maintained and reviewed. • Expect all communications and records related to treatment to be treated as private and confidential. • Receive written notice that explains how your information will be used and shared with other health care professionals involved in your treatment. • Review and request copies of your treatment records unless restricted for legal reasons. • Review, obtain, request, and receive a detailed explanation of your treatment charges and bills. • Report any concerns or complaints regarding your treatment to the agency Director. This will not affect your future care. • Expect a timely response to your complaint or grievance for the agency Director. This may be made in writing, by phone, or in person.

Responsibilities We ask that you: • Provide accurate and complete information about current health, education, and behavioral information. • Provide a copy of any recent evaluations, diagnosis, medical records, or other health/ educational documentation that is important to treatment. . • Recognize and respect the rights of other clients, families, and providers. Threats, violence, or harassment will not be tolerated. • Comply with the agency’s no smoking policy. • Be actively involved in your child’s treatment by participating in education, training, and observation of sessions as recommended by your provider. • Ask questions if you are concerned about your treatment. • Are responsible for paying your bills related to services rendered in a timely manner. • Follow your treatment plan as developed by your provider(s) and participate in the development of your child’s treatment plan. • Notify the clinic office at 941-758-4707 if you must cancel a scheduled session or wish to change or discontinue services.

6215 Lorraine Road • Lakewood Ranch, FL • 34202 • (941) 758‐4707

1

Parent/Client Intake Questionnaire

Child’s Full Name: ______________________________________________________________

Nickname: ___________________________ Date of Birth: ________________________

Gender (circle): Male or Female Age:___________________

Caregivers: ___________________________________________ Phone # _________________

Address: _____________________________________________ Email: ___________________

Name/Age of Sibling(s): _________________________________________________________

School/Daycare: ___________________________________________ Grade: _____________

Medical History

Pregnancy Length (weeks): _____________ Delivery (circle): head-first, feet-first, C-section

Mother’s health during pregnancy: _________________________________________________

Pregnancy complications: ________________________________________________________

Does your child have any history of the following (Check any that apply):

____ear infections ____ear tubes ____strep

____skin problems/eczema ____difficulty sleeping ____dark circles under eyes

____loose stools ____constipation ____food allergies (list)

____difficulty breathing/asthma ____dental problems ____seizures

____feeding difficulties ____physical deformities ____refusal to eat/FTR

____poor attention/easily distracted ____frequent falls/poor balance

Comments: ____________________________________________________________________

______________________________________________________________________________

Has your child had any of the following tests (Check any that apply):

____ vision screen/test date/results: _____________________________________

____ hearing screen/test date/results: _____________________________________

Primary Language spoken in the home: _______________ Secondary: ___________________

Hand Dominance (circle): right left


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Developmental Milestones

At what age did your child do the following:

Sit: ____________ Crawl: _________ Feed Themselves: _________

Talk:___________ Walk: __________ Toilet Trained: ___________

Dressing: _______ Shoe-tying: ______

Did your child have difficulty with any of the following:

____sucking ____swallowing

____chewing ____changing to solid food

Is your child a picky eater? _______ If yes, what types of foods does s/he prefer?

__________________________________________________________________

Medications:___________________________________________________________________

______________________________________________________________________________

Allergies:______________________________________________________________________

______________________________________________________________________________

Communication (Please complete each skill that your child CAN do independently):

At what age did your child do the following:

Babble ____________ Understand speech ___________ Imitate sounds ____________

Say first word(s) _____________ Combined words ____________

Does your child:

____point to an item of interest ____bring an item to you for help

____label everyday objects ____combine two words (Mommy juice, go car)

____respond when name is called ____ask questions (what/where/who)

____use phrases appropriately ____use other’s name to get attention

____greet others (hi/bye-bye) ____comment to another (Look, it’s a ______!)

____ask for help ____answer by saying “yes” or “no”

____follow instructions ____understand what s/he is being told

Does your child echo or repeat words immediately after hearing them or at a later time?

_________________________

Does your child repeat phrases from a favorite video/song/movie? ________________________

Is your child’s speech easily understood by others? ____________________________________

How many words does your child speak? ____________________________________________


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Does your child understand what you say to him/her? __________________________________

Did your child ever experience a loss or regression in his/her speech? ______________________

If yes, at what age did you notice this? ______________________________________________

Behavior:

Does your child exhibit any of the following (Check any that apply):

____seem in his/her own world ____attached to unusual objects (stick, hair, string)

____resistant to change ____difficulty transitioning

____excessive tantrums ____aggression (hit, push, bite others)

____eats/chews on non-food items ____watches the same video repeatedly

____mood swings ____spins body or objects

____dislikes certain textures ____clumsy

____little or no sense of safety ____high pain tolerance

____can’t sit still (hyperactive) ____climbs/jumps on furniture frequently

____hurts self (bangs/hits head) ____seem to “space out” at times

____non-compliance ____property destruction

____lack of respect for authority ____poor frustration tolerance

Does your child have a history of behavior problems in school? ____________________

Is your child’s behavior different in certain settings or with certain people? ___________

________________________________________________________________________

Does your child become obsessive about one or several topics?

_______________________________________________________________________

Does anyone in your family have a history of a condition which affected his/her development,

ability to learn, or mental health? _________________________________________________

____________________________________________________________________________

Please list your primary concerns regarding your child’s development:

______________________________________________________________________________

______________________________________________________________________________

Please list any community resources that your family is currently utilizing:

______________________________________________________________________________

Please return to the office or therapist

Documents

Pinnacle Pediatric Therapy Group