HOW DID YOU HEAR ABOUT
ELITE THERAPY CENTER?

DISCIPLINE

PATIENT INFORMATION

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACT

PHYSICIAN INFORMATION

INSURANCE

PATIENT RELEASE and INSURANCE AUTHORIZATION

(Initials are required for release of Medical Information and Authorization of Payment)

1. I hereby authorize payment directly to the Center for the benefits due to me in my pending claim and/or Major Medical Benefits otherwise payable to me, but not to exceed the physician’s and/or the Institutes regular charges for therapy for this treatment period.
2. I further authorize the release of any medical information required by my insurance carrier(s) and/or treating physicians.
3. I acknowledge it is MY responsibility to report any changes in insurance coverage including additional coverage or policy changes.

PATIENT CONSENT AND ACKNOWLEDGEMENT
OF RECEIPT OF PRIVACY NOTICE

I understand that as part of the provision of healthcare services, Elite Therapy Center creates and maintains health records and other information describing among other things, my health history, symptoms, examination, and test results, diagnoses, treatment and any plans for future care or treatment.

I have been provided with a Notice of Privacy Practices that provides a more complete description of the uses and disclosures of certain health information. I understand that I have the right to review the notice prior to signing the consent. I understand that the organization reserves the right to change their Notice and Practices and are prior to implementation they will mail a copy of any revised notice to the address I have provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations (quality assessment and improvement activities, underwriting, premium rating, conducting, or arranging for medical review, legal services, and auditing functions, etc.) and the organization is not required to agree to the restrictions requested.

By signing this form, I consent to the use and disclosure of protected health information about me for the purposes of treatment, payment, and healthcare operations. I have the right to revoke this consent, in writing, except where disclosures have already been made in reliance on my prior consent.

This consent is given freely with the understanding that:

1. Any and all records, whether written or oral or in electronic format, are confidential and cannot be disclosed for reasons outside of treatment, payment, and health care operations without my prior written authorization, except otherwise provided by law.
2. A photocopy or fax of this consent is as valid as this original.
3. I have had the right to request that the use of my Protected Health Information, which is used or disclosed for the purposes of treatment, payment, or health care operations, be restricted. I also understand that the Practice and I must agree to terminate any restrictions in writing on the use and disclosure of my Protected Health Information, which have been previously agreed upon.

ADMISSION FORM COMPREHENSIVE
TREATMENT PLAN AGREEMENT

The following is a description of this clinic’s policies regarding the comprehensive treatment plan. Please read and indicate your agreement to abide by these policies by initialing and signing where indicated. If you have any questions about these policies, please ask a representative of this clinic before signing.

Non-Discrimination Policy: Elite Therapy Center does not discriminate against any person on the basis of race, color, national origin, disability, or age in admission, treatment, or participation in its programs, services, and activities or employment. For further information, contact the Front Office Supervisor or TTY State Relay at 1-800-735-2988. Speech Hearing and Visual assistance communication guides are available at no charge and upon request. For further information, contact the Front Office Supervisor or TTY State Relay at 1-800-735-2988.

SCHEDULING POLICY and CONSENT to TREAT

I, Patient/Parent or Legal Guardian, hereby consent to treatment for therapy services. I further understand that once a weekly treatment appointment schedule has been determined, this clinic is often unavailable to accommodate changes for temporary periods of time. When a permanent change in time is needed, I must give as much advance notice as possible for the clinic to attempt to accommodate this request. A change in time may necessitate a change in therapists as well. Understand in order to receive maximum benefit from treatment, it is important for treatment to occur each week. I understand that I have to give two weeks from the time of cancellation to make up for the canceled session. I understand that I will lose the canceled session if not made up within two weeks. I understand that a makeup session may occur with this clinic's substitute therapist, our regular therapist, or another skilled therapist with this clinic and may be offered as a separate session or by adding on additional time to several sessions.

I understand that notification of vacations or family obligations are requested at least two weeks prior to the expected absence. Please notify the Elite Therapy Center business office to reschedule your appointment. I understand that we are entitled to make up sessions for vacation time two weeks before the following or vacation time.

I understand that the clinic is open except in cases of severe weather conditions requiring businesses to close. It is my responsibility to call the clinic to determine whether changes in the scheduled time of treatment are needed and if the opening of the clinic has been delayed. Families may cancel treatment if they do not wish to travel and in poor weather conditions. I understand that treatment time falls on a federal holiday that I am encouraged to make up the sessions.

I understand that if our therapist is ill or on vacation, the clinic will provide a substitute therapist to ensure the continuation of services. This clinic will make every effort to schedule the therapist at our regularly scheduled appointment time. If this cannot occur, the clinic will provide an alternate appointment time.

I understand that if we do not keep a scheduled appointment or if we do not cancel a session before the session is scheduled to begin, that time of treatment is forfeited.

I have read and agree to abide by the above policies.

OFFICE POLICY FOR FAMILIES

I understand that infants and toddlers often need to be accompanied by a parent during treatment; all other individuals are asked to please wait in the waiting room during treatment sessions. Observations of my child's treatment session may be conducted at any time.

I understand that I am responsible for waiting with my child in the waiting room until the treatment session begins and monitoring my child's play in the waiting room. I understand that it is the policy of this clinic that a parent or legal guardian must remain in the clinic during treatment sessions.

ACKNOWLEDGMENT OF RISK

I understand that there is some risk in the use of therapeutic equipment at this clinic, and I agree to indemnify and hold the clinic harmless for any and all losses and claims for any injuries occurring to my child or myself from the use of therapeutic equipment.

COORDINATION OF CARE

I give permission to have this clinic contact and discuss my child's/my case with all persons whose names I have provided as professionals working with my child or myself. I give permission for this clinic to send copies of the progress report to our referral sources whose name(s) I have provided.

TEACHING and EDUCATION of STUDENTS

I give permission for occupational, physical, and speech therapy students to observe me for my child's therapy. I understand that I will be notified before such observations take place.

CONSENT to PHOTOGRAPH/FILM

I give permission for photographs/video to be taken of myself or my child for educational and/or promotional purposes. I understand that any photographs or videos will be reviewed by Elite Therapy before they are released.

PATIENT RESPONSIBILITIES

Purpose - To inform the patients of their responsibilities as a participant in the total care process.

Policy - All patients are responsible for

1. Behavior showing respect and consideration for other patients, family, visitors, and personnel of the Elite Therapy Center.
2. Assurance the financial obligations for health care rendered are paid in a timely manner.
3. Accepting consequences of their actions if they should refuse a treatment or procedure, or if they do not follow or understand the instructions given to them by the physician or their health care team member.
4. Providing Elite Therapy Center, to the best of their knowledge, with an accurate and complete medical history about present complaints, past illnesses, hospitalization, surgeries, and the existence of advance directives, medications, and other pertinent data.
5. Following the plan of treatment recommended by the doctor primarily responsible for the patient’s care and/or other personnel authorized by the Elite Therapy Center to so instruct patients.
6. Notifying Elite Therapy Center of any change in their condition or circumstances.
7. Keeping their appointment for scheduled services. If they anticipate a delay or must cancel the scheduled service, it is their responsibility to notify Elite Therapy Center as soon as possible.
8. The disposition of their valuables while at Elite Therapy Center is the responsibility of the patient or guardian.

ADVANCE DIRECTIVES POLICY

Elite Therapy Center requires each person receiving treatment in this facility to sign the following notice to be in compliance with the Self-Determination Act regarding advance directives. In this facility, should a patient suffer a life-threatening situation, this signed notice implies agreement on the resuscitation and transfer of the individual to higher medical care. Therefore, any previously signed advance directives, including a durable power of attorney, will not be observed in this facility. Concerns regarding this policy need to be addressed with your physician. I have read the above policy and understand the information in this policy.

SICK POLICY CONSENT

It is the policy of the Elite Therapy Center that in the event the patient becomes ill, Elite Therapy Center will utilize the following guidelines for re-admitting patients into treatments as listed below:

Cancel appointment if one or more of these conditions are present:

• Oral temperature of 100 degrees or above
• Vomiting, nausea or severe abdominal pain
• Marked drowsiness or malaise
• Sore throat, acute cold, or persistent cough
• Red, inflamed or discharging eyes
• Acute skin rashes or eruptions
• Swollen glands around jaws, ears, and neck
• Suspected scabies or impetigo
• Any skin lesion in the weeping stage
• Earache
• Pediculosis (head lice)
• Diarrhea: runny, watery, or bloody
• Other symptoms suggestive of acute illness

Return to Therapy Guidelines:

• Fever free for a full 24 hours
• Symptom-free of vomiting, nausea, or severe abdominal pain
• Symptom-free of marked drowsiness or malaise
• Symptom-free of sore throat, acute cold, or persistent cough
• Treated pediculosis (head lice)
• Symptom-free diarrhea: runny, watery, or bloody
• All health conditions listed above have been treated and resolved

I agree to reschedule my appointment or my child’s appointment after the illness has been treated and resolved.

ARBITRATION AGREEMENT

In consideration of Elite Therapy Center agreeing to treat me as a patient, I hereby agree that any controversy between us, of whatsoever nature, will on the written request of either party, served on the other, be submitted to arbitration. The arbitration proceeding will comply with and be governed by the provisions of the Texas General Arbitration Act, Chapter 171 of the Texas Civil Practice and Remedies Code. Should Arbitration be revoked by either of us, then each one of us will appoint one person as an arbitrator to hear and determine the dispute. If they are unable to agree, then the two chosen arbitrators will select a third impartial arbitrator whose decision will be final and conclusive on us, the parties to this agreement. The expense of arbitration proceedings conducted pursuant to this agreement will be allocated between us as decided by the arbitrators.

ARCUERDO de ARBITRAJE

En consideración y concordancia con Elite Therapy Center para tratarme como un paciente, yo por medio de la presente estoy de acuerdo que cualquier tipo de controversia entre nosotros, que ocurra en el period de servicio requerido, será sometida a arbitraje. El procedimiento de arbitraje será conformado y será regido conforme a lo establecido en el Acta de Arbitraje General de Texas, Capítulo 171 del Código de Practicas Civiles y Remedios de Texas. El Arbitraje podrá ser solicitado por cualquiera de las dos partes, entonces cada una de las dos partes designara a un Árbitro para oir y solucionar la disputa. Si los dos árbitros escogidos no se pusieran de acuerdo, entones ellos dos podrán nombrar un tercer árbitro que sea imparcial cuya decisión será final y concluyente para las dos partes en la disputa. Los gastos del Arbitraje serán divididos entre las dos partes y según como lo decidan los Árbitros.

MEDICAL HISTORY QUESTIONNAIRE

PHYSICAL THERAPY

AGE AND DEVELOPMENT MILESTONES

PARENT CONCERNS

SELF HELP

DRESSING

PSYCHOLOGICAL AND PLAY

EDUCATION

ALLERGIES and MEDICATION LIST

AUTHORIZATION to TRANSFER SERVICE PROVIDER

ATTENDANCE and CANCELLATION POLICY

Thank you for filling out information to become a New Patient with Elite Therapy Center. We are pleased you have selected us to provide the highest quality speech, occupational and physical therapy service to your child on their journey of hope and healing.

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