Intake Form | Lori Kilpatrick Pedi

Patient Intake Form

GENERAL NEW PATIENT INTAKE FORM

Please complete the new patient general information intake form below. After submitting this form, click the MEDICAL HISTORY FORM TAB BELOW to complete the Medical History information.

Parent/Legal Guardian Name

Mailing Address

Phone

City

State

Zip Code

Insurance Provider

Policy Holder Name

Insurance Group #

Insurance Member ID

Policy Holder DOB

Policy Holder SSN

Upload Insurance Card

Upload File

Relationship to patient

CHILD INFORMATION

Child Full Name

Child Date of Birth

Child Gender

Child Race/ethnic group

Ordering Physician

Diagnosis

Your Pharmacy

FAMILY INFORMATION

Does child speak the language?

Other language spoken in home?

Does child understand the language?

Who in home speaks the language?

child language prefererence at home?

Reason for visit

Financial Responsibility

The undersigned, in consideration of medical services rendered by Lori Kilpatrick to the patient named below, does hereby agree to pay Lori Kilpatrick on demand for said services and incidents on behalf of such patient. I understand there will be a $20.00 charge for all returned checks.

Authorization to Obtain or Release Medical Information
Lori Kilpatrick is hereby authorized to release to my insurance company any medical information and records required in the processing of applications for financial coverage or insurance benefits for all services rendered to the patient. Further, I hereby authorize Lori Kilpatrick to release any medical records and information including medical records and information generated by Lori Kilpatrick and its related health care providers and facilities any and all records and information obtained from any other outside party as may be necessary for purposes of subrogation and/or direct recovery and coordination of benefits. I authorize Lori Kilpatrick to exchange information with my referring Physician regarding my treatment. Information may pertain to my treatment, compliance with treatment and reactions to treatment.

Assignment of Insurance Benefits
I hereby authorize direct payment of any insurance benefits to Lori Kilpatrick. I understand that I am personally responsible to Lori Kilpatrick for all charges and services.

No Show/Cancellation Policy
We understand that situations may arise in which you may not be able to keep a scheduled appointment for your child, therefore we ask you to please give us at least a 24-hour notice.

Services will be discontinued and your child will be discharged from therapy if any of the following are met:
Two (2) consecutive "no-show" appointments (missed appointments with no previous notice either by phone call or text to your child's Speech Therapist.
Four (4) cancellations within a 2-month period.

I understand that if I am not able to keep my child's therapy appointment, I will notify my child's Speech Pathologist by phone call or text. Or I will call Vianca Aybar (Office Manager) at 228-334-5035 or 228-297-7984.
I understand that failure to comply with this policy will result in termination of services.
I understand the above policy and agree to comply.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. The terms of this Notice of Privacy Practices (“Notice”) apply to Lori Kilpatrick Pediatric Therapy, its affiliates and its employees. Lori Kilpatrick Pediatric Therapy will share protected health information of patients as necessary to carry out treatment, payment, and health care operations as permitted by law. We are required by law to maintain the privacy of our patients' protected health information and to provide patients with notice of our legal duties and privacy practices with respect to protected health information. We are required to abide by the terms of this Notice for as long as it remains in effect. We reserve the right to change the terms of this Notice as necessary and to make a new notice of privacy practices effective for all protected health information maintained by Lori Kilpatrick Pediatric Therapy. We are required to notify you in the event of a breach of your unsecured protected health information. We are also required to inform you that there may be a provision of state law that relates to the privacy of your health information that may be more stringent than a standard or requirement under the Federal Health Insurance Portability and Accountability Act (“HIPAA”). A copy of any revised Notice of Privacy Practices or information pertaining to a specific State law may be obtained by contacting our office.

YES - Notice of Privacy Practices By checking this box, I have reviewed a copy of Notice of privacy Practices as a requirement of the privacy regulations issued under the Health Insurance Portability and Accountability Act of 1996.

YES - Media Release By checking this box, I grant permission for Lori Kilpatrick Pediatric Therapy, LLC to use photos of my child for marketing and advertisement purposes.

Your Signature - By checking this box and signing below, I agree to the terms listed within this form. I confirm that I am the authorized parent/legal guardian for the child as detailed within this form.

Thanks for submitting our patient intake form. Please continue below to complete our Patient Medical History form.

Please CONTINUE, click the button below to complete the MEDICAL HISTORY SECTION.

MEDICAL HISTORY FORM