New Admissions

Services Requested at BLPTC

OT (fine motor skills, self-care, regulation, etc.)

PT (crawling, walking, jumping, stairs, balance.)

ST (delayed talking, stuttering, understanding, articulation difficulty, etc.)

Feeding Therapy (texture aversion, picky eating, difficulty swallowing, aspiration, etc.)

Please tick at least one box.

Child’s Name

Answer all that apply pertaining to any evaluations your child has had in the last 6 months.

Individualized Education or Family Service Plan

NOTE: If your child's insurance is any form of medicaid, if the child has an IFSP or IEP, submission of that document is required to acquire authorization.

I consent to be contacted by the phone numbers and emails below:

Primary Contact Name

Secondary Contact Name

If anyone other than the parent(s)/guardian(s) listed above brings my child to therapy (such as grandparent(s), babysitter(s), family friend(s), etc.), I authorize the therapist(s) working with my child to discuss that therapy session with that person/persons.

! Attention Parents !!

If you have ANY insurance policy IN ADDITION TO A MEDICAID POLICY, you MUST disclose that information. Failing to notify us is considered FEDERAL INSURANCE FRAUD and could result in loss of Medicaid Benefits!! You will be fully responsible for all unpaid claims as a result of any undisclosed policy.

Secondary Insurance

NOTE: If your child's insurance is is Amerigroup or Peachstate or Caresource, a hearing evaluation is required to be submitted to obtain authorization for speech therapy.

Specialists Seen

For example, orthopedic, neurologist, GI, psychologist, etc.

Surgeries, Procedures, and Diagnostic Testing

Examples: MRI, Swallow Study, X-Ray, Allergy Testing, CT Scan

Contraindications/Precautions

None

Baclofen Pump

Seizure Condition

Insulin Pump

Vagal Nerve Stimulator

Shunt

G-tube

Other

Please tick at least one box, or “None”.

Milestones

Primary Communication

Verbal

Vocalizations

Single Words

Phrases

Sentences

Non-Verbal

Body Language

Eye Gaze

Facial Expressions

Manual Sign Language

Pointing/Gesturing

Alternative Augmentative Communication (AAC Device)

Areas of Difficulty

None

Understanding words

Communications needs

Articulation

Stuttering

Please tick at least one box, or “None”.

Description of Child — select all that apply; MUST select at least one

Active

Difficult to comfort

Persistent

Shy

Withdrawn

Aggressive

Stubborn

Insecure

Passive

Fussy

Motivated

Fearless

Fearful

Demanding

Distractible

Curious

Cautious

Affectionate

Calm

Please tick at least one box.

Beyond Limits Pediatric Therapy Center will now contact patients for appointment reminders using text messages and email messages through our HIPAA compliant electronic medical records system (EMR). In these notifications, you will have the option to confirm or cancel. Please do so immediately upon receipt. If you need to reschedule your appointment, please call the office at 770-917-5737.

Beyond Limits does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan (contact your carrier for pricing plans and details). You can opt-out anytime by signing our revocation form. Ask the front desk for more information.

Yes, I consent to receive text messages and emails for appointment reminders from Beyond Limits Audiology to my cell phone (and any number forwarded or transferred to that number) and to my email (and any email forwarded or transferred to that email) to receive communication as stated above.

No, I do NOT give consent to be contacted via text message and email for appointment reminders.

Purpose

At Beyond Limits Pediatric Therapy Center, we believe that consistent attendance is critical to every child's success in therapy. Along with home exercises and activities recommended by your child's therapist(s), regular attendance is essential for achieving the goals set forth in your child's individualized plan of care.

Importance of Attendance

Ongoing insurance approvals are contingent upon the patient's attendance and the parent/guardian's demonstrated commitment to home exercises. To support our mission of ensuring each child reaches their goals in the anticipated time frame, we have established the following attendance policy.

Scheduling Options

To accommodate different family circumstances, we offer two scheduling options:

Ongoing Recurring Appointments: For families with predictable schedules who can commit to consistent appointment times, with changes only for extenuating circumstances.

Flex Scheduling: For families with unpredictable schedules or additional commitments (e.g., frequent doctor’s appointments, sports activities). Under this option, patients must schedule and attend appointments for each service recommended at least twice/month. To progress and achieve goals in the anticipated time frame, it is encouraged that every patient attend therapy at the frequency recommended by the plan of care. However, failure to attend sessions of a particular therapy at least twice/month will result in discontinuation of treatment.

Please select one scheduling option before the first therapy visit (beyond the evaluation).

Attendance Policy for Ongoing Scheduling

Cancellations: Each patient is allowed two cancellations per patient (NOT PER SERVICE/THERAPY/DAY OF THERAPY) in a pre-established two-month period without penalty. Makeups for missed appointments are strongly encouraged.

No-Shows: An appointment is considered a no-show with less than 30-minutes notice, no notice, or a tardy exceeding 15 minutes. Upon the second no-show, the patient transitions to flex scheduling.

Transition to Flex Scheduling (Cancellations): On the third cancellation, the patient will be moved to flex scheduling unless at least one previous cancellation has been made up before this third occurrence. If one previous cancellation was made up, families may choose flex scheduling or adjust their ongoing appointment time.

Notification for Makeups: Parents/guardians must inform the front desk upon arrival for a makeup session to receive credit.

Multiple Appointments: With multiple services per week, any three cancellations combined (across all therapies) leads to flex scheduling for all therapies.

Occurrences Per Absence: If multiple therapies occur on the same day and are missed, it counts as one cancellation total, not multiple.

Attendance Policy for Flex Scheduling

Consecutive Attendance for Return to Ongoing Scheduling: Attending four consecutive appointments on flex scheduling allows families to request returning to ongoing scheduling (subject to availability).

Day-to-Day Flex: A no-show on week-by-week flex scheduling results in day-to-day scheduling, where appointments can only be scheduled on the same day.

Return to Week-to-Week Flex: Attending four consecutive day-to-day flex appointments allows a return to week-to-week flex scheduling.

Discontinuation of Treatment: Missing a day-to-day flex appointment may result in discontinuation of treatment.

Conclusion

We appreciate your understanding and commitment to your child's therapy journey. By adhering to this attendance policy, we help ensure that all patients receive the consistent care necessary to achieve their goals. Thank you for partnering with us in your child’s success!

Parent/Guardian Acknowledgement

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about your child. We understand that his or her medical information is personal to you and we are committed to protecting that information. As our client, we create medical records about your child’s health, our care for him/her, and the services we provide for your child. By law, we are required to make sure that your child’s protected health information is kept private. Beyond Limits Pediatric Therapy Center (BLPTC) is a teaching facility that allows students to observe our therapists and/or participate in the treatment of patients for school requirements. No information will be shared outside of the therapy session. By signing this form, you consent to our use and disclosure of protected health information about your child for treatment, payment, and healthcare operations. This practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). You also acknowledge that the BLPTC Privacy Notice (Revision Date, October 1, 2018) has been made available to you. This Notice is also displayed in our office and on the BLPTC website www.beyondlimitstherapy.org. If you are completing these forms online, please click here to see our Notice of Privacy Policies. A paper copy of this Notice will be provided any time it is requested.

I understand that by initialling here, the office staff of Beyond Limits has permission to routinely email updated evaluations/plans of care for my child to me at

when said records become available. This will help insure that the parent/guardian of the child is appropriately informed of the goals/objectives being worked on in therapy in order to continue those efforts in the home setting.

Please inital that you agree to the Receipt of Records.

I, (parent/guardian), knowing that (child’s name) has a diagnosis that may benefit from physical, speech, or occupational therapy treatment, voluntarily consent to such care for the aforementioned child by the therapist doing business for BLPTC as may be beneficial in the professional judgment of my child’s therapist. I consent to care and treatment that falls within the scope of practice as defined by the State of Georgia for each discipline.

I understand that treatment will involve physical participation on the part of the patient, which may involve risks of injury. I acknowledge that I am responsible for making my therapist(s) aware of any changes in my child’s physical or mental status. I release BLPTC, its therapists, students, staff and independent contractors from any liability for any accident or injury that is not directly caused by negligence.

BLPTC may utilize independent contractors for evaluations and therapy sessions. These include, but are not limited to, speech therapists, occupational therapists, physical therapists, and consulting and referring physicians. Healthcare professionals that are independent contractors are not agents or employees of BLPTC and are responsible for their own actions. I understand that BLPTC shall not be liable for the acts or omissions of independent contractors. This Consent to Treatment also applies to any independent contractor utilized by BLPTC.

BLPTC likes to use pictures/videos of students/clients/therapists/staff on our website, social media, brochures, invitations, slideshows, educational, and other programs. This form allows or prohibits BLPTC to use your child’s picture or videotape for marketing, educational or other purposes. Please select an option and initial next to your selection. I understand that the information authorized shall not be released beyond the mediums indicated and that any other uses other than those listed above shall be communicated with me beforehand. I also understand that the parties hereby authorized shall not be responsible for any unauthorized uses that may result by any person copying or hacking the previously identified mediums without proper authorization. I further understand that this consent may be revoked by me at any time by submitting a written revocation notice. I understand that this authorization will remain in effect until such time that I rescind my consent via written notification.

If you are a foster parent bringing a foster child to therapy, please select ‘No’.

Insurance information will be needed before services can be scheduled to verify benefits. A copy of your insurance card(s) and driver’s license is required. Benefits will be verified upon receipt of your insurance information and you will be made aware of any estimated out-of-pocket expenses. Information gained from insurance companies during verification of benefits is an estimation only and is not guaranteed. By initialing below, you acknowledge that BLPTC will attempt to obtain or confirm benefits and coverage information from your insurance company or other third-party payer, but that this is not a guarantee of coverage or payment, nor does it release you from any financial obligation for the services your child receives.

By initialing below, you acknowledge that it is your responsibility to notify BLPTC of any changes at any time in insurance or Medicaid coverage prior to receiving treatment. If you fail to notify BLPTC of any change in coverage and services are denied or non-covered, you will be responsible for the full amount of charges for services rendered at our self-pay rate. It is federal fraud to fail to notify us of any other insurance coverage you may have in addition to any form of Medicaid.

If the services your child receives from BLPTC are covered by a third-party payor, BLPTC agrees to file a claim and accept payment from such third party. If the third-party payor determines that a portion of the claim(s) are your responsibility, you will be required to make payment upon receipt of services or at the receipt of notification of such responsibility, as is appropriate. In the case of services which you agree to receive, but which are not covered by the third party, payment will be due upon receipt of services.

It is imperative that families are aware of their insurance coverage and their potential responsibilities. We will strive to keep open communication in regards to insurance and payment. If you do not have insurance coverage for therapy services, a payment plan may be arranged. Payment for private pay services is due at the time of service. Please check with the office to verify the in-network insurance providers. If your child’s insurance is out-of-network, you will be charged our cash pay rate. Receipts or other documentation that is required by your insurance company can be provided to you in order for you to file a claim for the services rendered.

A 10% late fee will be added to any invoice where payment has not been received within 30 days of receipt. Therapy services may be put on hold or terminated if there is a problem regarding payment. There is a $39 service fee for all returned checks. Please do not hesitate to contact us regarding questions of billing/payments. We are willing to work with each client to ensure a balance between providing therapy services and addressing business issues or concerns.

By signing below, I authorize BLPTC to bill my insurance company for direct reimbursement of therapy services rendered to my child and authorize release of any medical information necessary to process the claim. I assign benefits for filed claims to be paid to BLPTC and will turn over any payments sent directly to me by my insurance provider that were intended to cover services provided by BLPTC. I understand that I am responsible for payment of any services not paid or not paid in full by insurance, including those not paid or non-covered as result of my failure to disclose policy coverage or change in policy coverage. By signing this document, I certify that I have read and understand its contents and that information provided by me is accurate and complete (including insurance information and current eligibility for benefits).