Case History – Age 4 And Older - Chatterbox Pediatric Therapy LLC

How did you hear about us?*

Physician referral
Word of mouth
Facebook/instagram
Google search
Magazine advertisement
Other

Name Of Physician

Name of Publication

Other Details

Clinic Location Child has appointment scheduled at*

Pooler
Richmond Hill

Child’s Name*

Birth Date*

Preferred Name*

Sex*

Male
Female

Parent/Caregiver*

Email*

Phone Number*

Primary Language

Address*

Child lives with*

Are there any guardianship/custody issues our office should be aware of?*

Yes
No

Please briefly describe*

Primary Care Physician*

Medical Diagnosis*

Primary Concerns/Reason for Referral*

Has your child previously received therapy before? Select all that apply.

ST
OT
PT

Where were services received and for how long?*

Why did your child discontinue receiving services?*

Emergency Contact(s)*

Phone*

Hospital Preference

In the event that my child becomes ill or injured while in therapy and guardians/emergency contacts are unable to be reached, I authorize the provision of emergency medical services to my preferred hospital. I give consent for the administration of any treatment deemed necessary by the treating physician. I understand that I will be liable for any costs associated under this consent to treatment.

Signature of Parent/Guardian*

Date*

FAMILY

Names and ages of siblings

Name	Age

Names and nicknames of family members close to your child: (ie: ‘nona’/grandmother)

Name	Nickname

Names of pets

PRE-NATAL & BIRTH HISTORY

Birth Type*

Premature
Full term
Birth uneventful
Birth eventful

How many weeks?*

Please describe*

Please describe any pre-natal issues

Was the child in the Newborn Intensive Care Unit?*

Yes
No

For how long?*

DEVELOPMENTAL MILESTONES

Sat at age

Walked at age

First words at age

Combined words at age

Please list any developmental milestones NOT met within appropriate timeframes

MEDICAL HISTORY

Please elaborate if any of the following are checked

Please list all surgeries and dates*

Surgery	Date

Please list all medications*

Name of Medication	What addressing?	Dosage	Side Effects

Please list allergies*

Ear infections-How frequently?*

GERD- age diagnosed*

GERD- How treated?*

GERD- Have symptoms resolved?*

Yes
No

Current Weight?*

Current Height?*

Please describe your child’s health in general

HEARING

Has your child had any ear infections?*

Yes
No

Please list dates and treatment*

Date	Where tested?	Results

Has your child had PE tubes placed?*

Yes
No

Has your child been diagnosed with hearing loss?*

Yes
No

What type and severity?*

Does your child regularly wear aided hearing device?*

Yes
No

VISION

Has your child had his or her vision checked?*

Yes
No

What were results?*

Does your child wear corrective lenses?*

Yes
No

Does your child have a history of Estropia, Strabismus, Patching or Eye drop prescriptions?*

Yes
No

Please specify*

DENTAL/ORAL HEALTH

Does your child regularly see a dentist?*

Yes
No

How often?*

Does your child allow you to brush his/her teeth?*

Yes
No

Has your child used a pacifier?*

Yes
No

At what age did the child stop?*

Does your child put toys or objects in his or her mouth?*

Yes
No

BEHAVIORAL CONCERNS

Please check all that apply

Comments

EDUCATIONAL INFORMATION

School/Educational Program Currently Attending

Grade Level

Does your child have an IEP?

Yes
No

Special Services Received

Does your child’s teacher express concerns with his or her development or educational performance?

Yes
No

In what areas: (please check all that apply)

Is there anything else that you feel would be beneficial for us to know about your child?

CONSENT

Please read and initial each item:

CONSENT TO TREAT*

I give consent for my child to receive the necessary evaluation and/or treatment by Chatterbox Pediatric Therapy.

RELEASE/REQUEST*

Permission is given to Chatterbox Pediatric Therapy to release and/or request information when necessary for the records of the above-named individual.

CONTACT INFORMATION*

I give consent to leave messages on my voicemail or reminder text messages at preferred number.

VIDEO SURVALLIANCE ACKNOWLEDGEMENT*

In an aid to enhance the quality of care, Chatterbox Pediatric Therapy may use an electronic surveillance system to record visual occurrences on the facility’s internal and external grounds, the only exception being private areas of restrooms. I acknowledgement that I am aware that Chatterbox Pediatric Therapy may use an electronic surveillance system and I understand that video surveillance may be used for training, saftey, and investigative purposes.

EMAIL CONSENT FOR APPOINTMENTS AND BILLING*

I acknowledge that Chatterbox can contact me through email for appointment, financial, and treatment updates. I understand the risks that are associated with using this form of communication, including but not limited to information regarding your child’s treatment may be accessible to other parties on the web. Chatterbox will use reasonable means to protect the information sent and received by email and will treat such email messages with the same degree of confidentiality as medical records. I understand that Chatterbox cannot guarantee the security and confidentiality of email communications and I still request to use this form of communication knowing risk factors. I may withdraw this consent at any time by written communication with the office manager. I understand that by completing this information I will be enrolled in the patient portal through Fusion Web Clinic.

I would like to receive my billing and financial statements through email

I understand the practices and policies of Chatterbox Pediatric Therapy that I have initialed above

PRIMARY INSURANCE

Insurance Company

Member ID number

Policyholder's Name

Group ID

Relationship to Policyholder:

Employer

Insured’s Address: if different from child’s

Date of Birth: (policy holder’s)

SECONDARY INSURANCE

Insurance Company

Member ID number

Policyholder's Name

Group ID

Relationship to Policyholder

Employer

Insured’s Address: if different from child’s

Date of Birth: (policy holder’s)

Effective July 2021 Chatterbox Pediatric Therapy will require every family with patient responsibility (private pay, co-pay/deductible amounts) to have a credit card on file. Co-payments and deductible plan pre-pays amounts will be run each Friday for that week’s appointments. Chatterbox requires that all patient balances remain below $300. Please list the credit card information below that you would like on file for your child. You may also verbally provide this to the office when you check in for your evaluation. You may change your method of payment any time.

Name on Card*

Card Number*

Expiration Date*

CVV (number on back of card)*

Zip Code*

I understand that patient responsibility for services provided by Chatterbox are due at the time services are rendered. I give Chatterbox Pediatric Therapy permission to charge my credit card listed above for copays/deductible plan pre-pays or any other financial payment plan arrangements made with Chatterbox Pediatric Therapy for services provided to my child.

Assignment of Benefits:*

Chatterbox Pediatric Therapy will make every effort to work with our clients regarding obligations for services whether payment may be through insurance, private pay, co-payment or other agreements.

I certify that the information given by me in applying for payment is correct. I hereby authorize payment by my insurance carrier of the benefits, otherwise payable to me, to be made directly to Chatterbox Pediatric Therapy for their services.

I authorize Chatterbox Pediatric Therapy to release all insurance companies and/or compensation carriers only such as diagnostic, therapeutic, and financial information as may be necessary to determine benefits entitled and to process payment claims for health services that will be provided.

I understand and agree that I am financially responsible for all co-pays, coinsurance and amounts not covered by my healthcare provider. This charge is expected at time of services.

I understand that I am obligated to provide ALL insurance information and must notify Chatterbox immediately should this information change. I understand that failure to comply with this policy will result in patient responsibility for any unpaid balances.

Chatterbox Pediatric Therapy Attendance/Cancellation Policy*

Dear Patients and families,

We would like to take a moment to thank you for choosing Chatterbox Pediatric Therapy for your child’s therapy needs. Our clinic strives to provide each patient with the highest quality of care while making every effort to accommodate your schedule. Therefore, we provide reserved time slots for each patient with a specific therapist in order to minimize your waiting and ensure continuity of your child’s treatment. Consistent attendance during therapy is critical for a successful therapy program.

We truly appreciate our patients and are committed to providing quality care to each of them. In order to accommodate all of our patients, we ask that you adhere to the following appointment policies:

Please arrive on time for your scheduled appointment. If you are more than 10 minutes late for your appointment time, your appointment may need to be rescheduled.
Please cancel appointments as soon as you know you will not be able to attend. This includes doctors appointments, vacations, illnesses, etc. A minimum of 24 hours notice is required for non emergencies.
Please make every attempt to reschedule non illness related missed appointments.
If an emergency occurs after our normal business office hours, please leave a message on the answering service, enabling us to follow up to reschedule your appointment and ample time to notify the treating therapist(s).
Please do not bring your children to therapy when they are ill. Be sure that the late cancellation fees will be used at the discretion of management. We do not want you to bring your children when they are sick out of fear that you will be charged. Many of us are parents. We understand.
Patients with attendance below 75% will result in the cancellation of all future regularly scheduled appointments and placed on flex-scheduling (week to week or same day only).
Repeated failure to comply with this Attendance Policy will result in your child losing their regularly scheduled therapy times. This will require you to call for an open appointment on each week/day you would like to receive therapy. We will do everything possible to accommodate you as space on the schedule permits.

No-Show/Late Cancellation Fees may be charged for repeat offenses of the following situations:

Failure to show for a scheduled appointment without proper notification of absence.
Failure to notify office of cancelled appointments within 24 hours of the scheduled appointment when applicable.
Chronic arrival to appointments beyond the 10 minute mark, resulting in cancellation of therapy.
A $25 No-Show/Late Cancellation fee may be waived in the circumstance that a no-show or late cancelled appointment is rescheduled and kept within one week of the missed appointment. Alternatively, if a no-show or late cancelled appointment is rescheduled and not kept, a $25 fee
may be applied to ALL missed appointments.
Full payment of any assessed cancellation fees must be paid in full before your child may return to therapy. Any unpaid no show or late cancellation fees over 90 days may result in turning the account over to a third-party collection agency.

We appreciate your cooperation and compliance with our attendance policy. We look forward to working together to help your child reach his/her full potential.

I have reviewed a copy of Chatterbox Pediatric Therapy’s Notice of Privacy Policies and Practices and authorize use and disclosure of my child’s health information for treatment, payment, and health operations. I understand that I can request a copy of this policy at any time.

Name of Child*

I GIVE CHATTERBOX PEDIATRIC THERAPY PERMISSION TO DISCLOSE MY CHILDS HEALTH INFORMATION TO:

Name Of Person (i.e family member)	Relationship to Patient

Chatterbox has our Privacy Policy posted in the waiting areas of each location and available for review at the time of check-in. Please let the office know if you would like a copy to take home with you. You can review the online copy here at any time.

Does your child receive school therapy services or early intervention services through an IEP or IFSP?*

Yes
No

Name Of School*

If yes, do you give Chatterbox permission to obtain the IEP or IFSP?*

Yes
No

Many insurances require IEPs and IFSPs for authorizations and payment for therapy services. Therefore, failure to allow Chatterbox to obtain these records may prevent your child from receiving services at Chatterbox Pediatric Therapy.

Release of Medical Records

I hereby request the release of records from the following entity (Please list child's school if they have an IEP)

Organization Name

Fax Number

Contact Person

Documents Requested

To be released to:

Chatterbox Pediatric Therapy, LLC 110 Pipemakers Circle, Suite 115 Pooler, GA 31322 Fax Number: 912-988-1537 Attention: Medical Records

Chatterbox Pediatric Therapy, LLC 2459 B US Highway 17 South Richmond Hill, GA 31324 Fax Number: 912-445-5653 Attention: Medical Records

Parent/Guardian Name*

Parent/Guardian Signature:*

Date*

Case History – Age 4 And Older

Intake Form – Age 4 And Older

FAMILY

PRE-NATAL & BIRTH HISTORY

DEVELOPMENTAL MILESTONES

HEARING

VISION

DENTAL/ORAL HEALTH

BEHAVIORAL CONCERNS

EDUCATIONAL INFORMATION

CONSENT

PRIMARY INSURANCE

SECONDARY INSURANCE

Release of Medical Records

Our Locations

Pooler

Richmond Hill

Intake Form – Age 4 And Older

FAMILY

PRE-NATAL & BIRTH HISTORY

DEVELOPMENTAL MILESTONES

HEARING

VISION

DENTAL/ORAL HEALTH

BEHAVIORAL CONCERNS

EDUCATIONAL INFORMATION

CONSENT

PRIMARY INSURANCE

SECONDARY INSURANCE

Release of Medical Records

Have Questions? Contact Us

Our Locations

Pooler

Richmond Hill

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