General Intake Form Step 1 of 12 8% Parent/Guardian First Name:* Parent/Guardian Last Name:* Primary Phone Number:*Alternate Phone NumberEmail Address:* Child’s Name:* Below is a list of items that must be completed as part of this Client Intake Packet. Required Forms: Client History Form Informed Consent Custodial/Court Documentation Acknowledgement Release/Obtain Information Form Health Policy Cancellation/Tardiness, Illness and HIPAA Policies Financial Policy Copy of Insurance Card (front and back) Optional Forms: Prior Evaluations IEP or 504 Documents Prescription for Services Client History FormChild’s Full Name: DOB: MM slash DD slash YYYY Parent or Caretaker’s Full Name: Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this address the same as your billing address? Yes No If no, please provide both your billing address:Who lives in the home with you? Relationship to Patient: Custody Full custody Other If other, please provide a copy of the custody agreement. *If partial or joint custody, both parties will need to consent to treatment. Alternate Email and Relationship to Patient: Language(s) Spoken at Home: How did you hear about EBS Children’s Institute? Emergency Contact InformationEmergency Contact Name 1: Relationship to Patient: Phone Number:Emergency Contact Name 2: Relationship to Patient: Phone Number: Present Medical InformationPhysician's Name: Office Name: Physician Phone Number:Physician Email Address: Describe present concern related to appointment:Have any previous therapies or approaches been attempted? Yes No If yes, please describe:Has there been any significant medical or behavioral changes in the past 6 months? Yes No If yes, what has changed?Please list any allergies:What is your child’s current health? Good Fair Poor Is your child taking any medications? Yes No If yes, please list medications: Does your child have any other medical diagnosis or concerns?Does your child have any adaptive or medical equipment?Indicate any illnesses, accidents, hospitalizations (include age/treatment):Does your child have problems hearing? Yes No If yes, please explain:Has your child experienced any ear infections? Yes No Approximately how often? Rarely Occasionally Often Has your child had middle ear tubes inserted? Yes No If yes, when? Has your child’s hearing ever been tested? Yes No Results: Did your child have his/her adenoids or tonsils removed? Yes No If yes, when? Does your child snore? Yes No Does your child wear corrective lenses (glasses, contacts)? Yes No If yes, at what age did your child begin to wear them? Therapy GoalsPlease describe your goals for therapy. What do you hope to accomplish?Are you in need of any additional supports besides what you are being seen for today? Yes No If yes, please describe: Birth HistoryWas pregnancy full term? Yes No Was there anything remarkable about the mother’s health during pregnancy or delivery? Yes No If yes, please explain:Type of Delivery: Vaginal Caesarian Breech Suction Forceps Was there any type of diagnosis or medical concern about the baby after birth? Yes No If yes, please explain:Please describe any family history of developmental or learning problems: Education/Therapy InformationIs your child enrolled in any type of childcare facility, preschool program, play group, developmental program, public school or private school? Yes No Name of School/Facility: How long have they attended? Hours Enrolled Per Week: Current Grade Level: Has your child ever had a school-based evaluation? Yes No Please briefly describe the results:Does your child have an IEP? Yes No What type of services do they receive?*Please provide a copy of the IEP and Evaluation to EBS Children’s Institute. Does your child receive speech/occupational/physical/counseling therapy at this time? Yes No Speech Therapy x/weekOccupational Therapy x/weekPhysical Therapy x/weekCounseling x/weekWhere are these services provided? Informed ConsentChild’s Name: CONSENT FOR THERAPEUTIC TREATMENT I hereby attest that I have voluntarily applied for and entered into treatment, or give my consent for the minor or person under my legal guardianship, at EBS Children’s Institute. I understand that I may terminate these services at any time. * I agree to the above. Date MM slash DD slash YYYY *IF SHARED CUSTODY: both parties must sign this consent prior to treatment. CONSENT FOR PARTICIPATION WITH THERAPEUTIC EQUIPMENT Intervention programs at EBS Children’s Institute usually involve the use of specialized equipment such as various swings, bolsters, inflated therapy balls, climbing structures, tactile media (such as soap foam, Play-Doh and lotion), and a variety of other activities that involve fine, gross and oral motor coordination. Therapy activities often involve encouraging the child to try new in order to foster increased skills and abilities. While EBS staff make great efforts to ensure each child’s safety, the nature of the therapeutic intervention includes the risk of falling, bumping into other people/equipment. I am aware of the inherent risk of this type of activity, and I give permission for my child to participate in therapy as described. * I agree to the above. Date MM slash DD slash YYYY REVIEW OF RECORDS/RELEASE OF INFORMATION I consent to communication between EBS Children’s Institute and other therapists, teachers, and/or doctors that have previously worked and/or are currently working with my child. I understand that information may be shared with another member of my child’s treatment team outside of EBS, as well as shared with professionals within EBS as part of the treatment process. I understand that the information that is released between the treatment providers is confidential and is for the well-being of my child. * I agree to the above. Date MM slash DD slash YYYY CONSENT FOR VIDEOTAPING AND PHOTOGRAPHING FOR THERAPEUTIC PURPOSES Therapists often videotape or photograph children who receive therapy services at EBS to help monitor and document a child’s areas of concern, as well as progress. Videotapes and photos are used and reviewed only by EBS staff. Parents are welcome to view their child’s videotape at EBS. I _____ give consent for my child to be videotaped and/or photographed as part of his/her therapy program for use by EBS Children’s Institute staff only.* Do Do Not CONSENT FOR VIDEOTAPING AND PHOTOGRAPHING FOR EDUCATIONAL AND PUBLIC AWARENESS PURPOSES Staff at EBS are frequently asked to teach at courses, seminars, or workshops. We often like to include videotape, slides or photos during our presentations. Additionally, we may occasionally use photographs to share on Social Media and for promotional purposes. I _____ give permission for my child to be videotaped/photographed for educational and public relations purposes. I understand that my child’s name and any identifying information, will not be used in association with these images.* Do Do Not Information About Graduate Interns and ObserversEBS Children’s Institute is dedicated to providing quality therapy services to our clients. As part of our mission, we also partner with local universities to provide quality training and mentoring to student clinicians who are completing their studies in the fields of Speech-Language Pathology, Occupational Therapy, and Physical Therapy. Therefore, your child may be seen for treatment by the regularly assigned therapist along with a graduate intern. Please be assured that the intern is receiving one-one mentoring from your child’s therapist and that the intern is a Master’s-level graduate student who has been carefully selected to train at EBS Children’s Institute. In addition, from time to time, we receive requests from the local universities to allow for undergraduate student clinicians to observe therapy sessions. These students are required to obtain a certain number of hours of observation before they can start a formal internship program. If you have any questions regarding our internship or observation programs, please see our Clinic Director so that your concerns can be addressed. We thank you in advance. - EBS Children’s Institute By signing at the end of this form I understand and consent to the possibility that there may be a graduate intern assigned to my child's therapy program and have the right to deny this consent at any time by alerting the Clinic Director. Child's Name: Parent's Name: Date: MM slash DD slash YYYY Custodial/Court Documentation AcknowledgementPlease select if true. I, the parent/guardian, do hereby acknowledge that there is NO custodial/court documentation in place for the child(ren) listed below as of today’s date. Child(ren)’s name(s): Today's Date MM slash DD slash YYYY OR, if the above is not true, complete the following portion of this form. I, the parent/guardian, do hereby acknowledge that there IS custodial/court documentation in place for the child(ren) listed below as of today’s date. In addition, I will provide the custodial/court documentation to EBS Children's Institute. Child(ren)’s name(s): Today's Date MM slash DD slash YYYY Consent to Release/Obtain InformationPlease check: I, the parent/guardian, do hereby authorize EBS Children’s Institute to RELEASE TO and OBTAIN INFORMATION FROM the record of the individual identified below for therapeutic purposes including collaboration, planning and treatment. Name of Individual: Name of Agency: Phone Number:Email Address/Fax Number: Name of Individual: Name of Agency: Phone Number:Email Address/Fax Number: Name of Parent/Guardian: Relationship to Child: Date MM slash DD slash YYYY Health PolicyFor the safety of your child, parents/guardians of children with Allergies, Asthma, or Seizures you must remain present either in the therapy room or the waiting area during the entire therapy session. If a seizure, asthma attack or allergic reaction occurs during a therapy session, the therapist will need to end the session. AllergyAllergy: Yes No Allergic to: Please describe reaction: Medications given: If you checked yes, please complete the following Allergy Plan. If you do not feel a plan is necessary at this time, please check the statement below. I do not feel my child needs an Allergy Plan at this time. Date MM slash DD slash YYYY Allergy PlanClick (+) to add items.AllergenReaction Click (+) to add items.Date of Plan: MM slash DD slash YYYY Child’s Name: Date of Birth: MM slash DD slash YYYY Parent/Guardian Name: Therapist/Staff Name: Phone Number:HomeCellCellOtherOtherPhysician Name: Phone Number:Emergency Contact: Emergency Contact Phone Number:HomeCellCellOtherOtherBrief description of child’s allergies and reactions:Click (+) to add items.If child displays the following symptoms:Take the following actions: Click (+) to add items. EBS Children’s Institute staff will do its part to be continually aware of child’s specific allergy. However, it is not possible to prevent 100% of all accidental exposures in a center which is frequented by a large group of clients and families each week. By signing at the end of this form, you understand that EBS Children’s Institute will not be held liable for any reactions that a child has when in contact with our clinic environment. Before serving your child, EBS will need a copy of your child’s emergency allergy plan. If the emergency plan requires medication (EpiPen, inhaler, etc.), we require parents to stay on the premises for the duration of the session. I agree to the above. Name: Relationship to Patient: Date: MM slash DD slash YYYY Clinician Signature: To be signed after form is submittedDate: Clinical Director Signature: To be signed after form is submittedDate: SeizureSeizures: Yes No Frequency: Please describe: Medications given: If you checked yes, please complete the following Seizure Plan. If you do not feel a plan is necessary at this time, please check the statement below. I do not feel my child needs a Seizure Plan at this time. Seizure PlanKnown Triggers for Seizures:Date of Plan: MM slash DD slash YYYY Child’s Name: Date of Birth: MM slash DD slash YYYY Parent/Guardian Name: Therapist/Staff Name: Phone Number:HomeCellCellOtherOtherPhysician Name: Phone Number:Emergency Contact: Emergency Contact Phone Number:HomeCellCellOtherOtherBrief description of child’s seizures:Click (+) to add items.If child displays the following symptoms:Take the following actions: Click (+) to add items. EBS Children’s Institute staff will do its part to be continually aware of child’s seizure history, avoid known seizure triggers, and monitor at all times for signs and symptoms. As it is not our policy to administer medications, a parent or caregiver must remain present either in the therapy room or the waiting area during the entire therapy session in case such an event may occur. In the event of a seizure EBS Children’s Institute staff will work with the family to safely position the child until he or she is stabilized or emergency medical service arrives. The therapy session will end if a seizure occurs. By signing at the end of this form, you understand that EBS Children’s Institute will not be held liable for any seizure that a child may have in our clinic environment. I agree to the above. Name: Relationship to Patient: Date: MM slash DD slash YYYY Clinician Signature: To be signed after form is submittedDate: Clinical Director Signature: To be signed after form is submittedDate: AsthmaAsthma: Yes No Known Triggers: Frequency: Medications given: If you checked yes, please complete the following Asthma Plan. If you do not feel a plan is necessary at this time, please check the statement below. I do not feel my child needs an Asthma Plan at this time. Asthma PlanKnown Triggers for Asthma:Date of Plan: MM slash DD slash YYYY Child’s Name: Date of Birth: MM slash DD slash YYYY Parent/Guardian Name: Therapist/Staff Name: Phone Number:HomeCellCellOtherOtherPhysician Name: Phone Number:Emergency Contact: Emergency Contact Phone Number:HomeCellCellOtherOtherBrief description of child’s asthma and reactions:Click (+) to add items.If child displays the following symptoms:Take the following actions: Click (+) to add items. EBS Children’s Institute staff will do its part to be continually aware of child’s asthma history, avoid known triggers and monitor at all times for signs and symptoms. As it not our policy to administer medications, a parent or caregiver must remain present either in the therapy room or the waiting area during the entire therapy session in case such an event may occur. In the event of an asthma attack, EBS Children’s Institute staff will work with the family to safely maintain the child which time the child is okay or emergency medical service arrives. The therapy session will end if an asthma attack occurs. By signing at the end of this form you understand that EBS Children’s Institute will not be held liable for any asthma attacks that a child may have in our clinic environment. I agree to the above. Name: Relationship to Patient: Date: MM slash DD slash YYYY Clinician Signature: To be signed after form is submittedDate: Clinical Director Signature: To be signed after form is submittedDate: EBS Children’s Institute will do its part to work with families of children with medical needs to ensure safety during our therapy sessions. By signing at the end of this form you agree that you have disclosed any known history of allergies, asthma, or seizures and will work with our staff to create a plan to address these concerns as needed. I agree to the above. Financial PolicyAs a courtesy to all of our patients, we will call to verify benefits and will make reasonable effort to collect from your insurance company, should you choose to utilize insurance. Please understand, however, primary responsibility for understanding coverage limits belongs to the parent. There are instances when insurance may deny benefits (deductible not met, services not covered under the plan, etc.) and you will then be responsible for payment. In the event that insurance denies payment, the family may wish to appeal the matter to their insurance company, and we will support the parent in their effort. Any payment which is deemed to be due from the parent (private pay/co-pays) is due at the time of the service. If a payment plan is required, those terms will be provided to you in writing and agreed upon by both EBS Children’s Institute and the person responsible for patient’s bills. Please inquire with our office administration regarding rates for services. Notification of Insurance Changes/Renewal Policy EBS Children’s Institute must have current information on file regarding Insurance at all times. It is the responsibility of the parent/guardian to know of any and all changes that may occur in your insurance policy. It is also the responsibility of the parent/guardian to be sure that EBS Children’s Institute is aware of any and all changes to the policy at or before the time that they go into effect. Please note: Many insurance policies change in January each year; however, they can change at any time. *Notification of Change: All changes must be directed to the Clinic Administration Staff and appropriate insurance card and identification provided. ALL PAYMENTS AND OUTSTANDING BALANCES ARE DUE AT THE TIME OF SERVICE. We thank you in advance for your cooperation and invite you to call the Clinical Director with any questions that you may have about billing. I have read and agree to my financial responsibility for the services provided to me by EBS Children’s Institute. This also certifies that the information I have provided to EBS Children’s Institute, to the best of my knowledge, is true and accurate. I authorize my insurance carrier to pay EBS Children’s Institute the full and entire amount of the bill incurred by my child. Child's Name: Date: MM slash DD slash YYYY Cancellation and Tardiness PolicyConsistency is vital to a successful outcome in the therapy process. In the event that your child is unable to attend sessions regularly, we will work with you and make every effort to accommodate your family’s needs by seeking to develop a solution that is in the best interest of your child. If your child’s attendance continues to be inconsistent and is no longer therapeutically appropriate, therapy may be placed on hold until consistency can be improved. Please review the guidelines below regarding the cancellation and tardiness procedures: Cancellation Policy: Your child’s therapist has reserved valuable time for your child’s treatment. Your therapist has prepared for the session and blocked out all other activity during this time. In the event that a therapy session is missed with less than 24-hour notice, a fee of $35 will be assessed to the family. If there are more than three absences without proper notice, in a period of six months, your appointments will be at risk for permanent suspension. Tardiness: Please call the clinic to notify us when you will be running late for your appointment. If there are more than three instances of tardiness (15 minutes or more) in a period of six months, your appointments will be at risk for permanent suspension. Illness: Please call the clinic as soon as you know that your child may miss your scheduled session. Refer to the illness policy for additional information. Vacation: Please inform the clinic at least two weeks prior to absence due to vacation. Other: Routine doctor visits, meetings, and other flexible appointments should be scheduled so they do not conflict with the existing therapy appointment. Therapy is an important part of your child’s schedule, and should be treated as such. Late fees and late cancellation fees must be paid prior to the child’s next session at the clinic. We understand that there are unavoidable instances that require cancellation of the session (illness, family vacation out of town, death in the family, etc.) and we are willing to work with families during these occasional circumstances. Chronic illness will be taken into consideration for continuation of therapy.Illness PolicyPlease understand that, while attendance is vital, it is also important to protect your child, as well as the health of the therapist and other children. We require children to be symptom and fever free for at least 24 hours prior to returning for a session. If a child is on an antibiotic for an illness, the medication must be administered for at least 24 hours before returning to the clinic. Please call the clinic as soon as you know that your child may miss your scheduled session due to illness. The following circumstances warrant cancellation (with possible rescheduling) of the therapy session: The child is unusually lethargic or irritable Presence of yellow or green mucus secretion Vomiting/diarrhea Fever (within 24 hours of session) Seizures Open skin sores Head lice or nits present The child is in a contiguous state of a communicable disease including by not limited to: Pink Eye Explained rash Strep Throat Chickenpox Ringworm - must be 24-48 hours on treatment and completely covered if rash is still present. HIPAA Notification Policy Please review our Notice of Privacy Practices carefully. The privacy of your health information is important to us. This notice describes how health information about you may be used and disclosed and how you can get access to this information. Our Legal Duty We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices or for additional copies of this Notice, please contact us using the information listed at the end of this Notice. Uses and Disclosures of Health Information We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. Payment: We may use and disclose your health information to obtain payment for services we provide to you. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative, or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use of disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up forms of health information. Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization. Required by Law: We may use or disclose your health information when we are required to do so by law. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having custody of protected health information of inmate or patient under certain circumstances. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as email and voicemail messages or letters). Patient Rights Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practically do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies, and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $.35 for each page, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.) Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12 month period, we may charge you a reasonable cost-based fee for responding to these additional requests. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances. Electronic Notice: If you receive this Notice on our website or by electronic mail (email), you are entitled to receive this Notice in written form. Questions and Complaints If you want more information about our privacy practices or have questions, please contact us. Clinical Director of EBS Children’s Institute 1500 S. Christopher Columbus Blvd. Floor 2 Philadelphia, PA 19147 Phone: 215-918-9310 Fax: 484-301-3114 Email: Katie.Killeen@ebsei.com If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services upon request. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. I have received a copy and agree to abide by the terms of EBS Children’s Institute: HIPAA Notification Policy Cancellation/ Tardiness Policy Illness Policy By signing at the end of this document, I acknowledge that I have received the Notice of Privacy Practices (Notice). The Notice describes, in accordance with the HIPAA Privacy Regulations, how EBSCT may use and disclose my child’s protected health information to carry out treatment, payment or health care operations and for the other specific purposes that are permitted or required by law. The Notice also describes my rights and EBS Children’s Institute’s duties with respect to protected health information about my child. Child's Name: Date: MM slash DD slash YYYY Notice of Privacy Practices Section A: To the Patient Please read the following statements carefully. Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations (TPO). Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices which will contain the changes. Those changes may apply to any of your protected health information that we maintain. With my permission, the office of EBS Children’s Institute may call my home or other designated location and leave messages on voicemail that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any call pertaining to my clinical care. With my permission, the office of EBS Children’s Institute may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminders and patient invoices and statements. With my permission, the office of EBS Children’s Institute may email to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder and patient invoices and statements. I have the right to request that EBS Children’s Institute restrict how it uses or discloses my protected health information to carry out TPO. However, the practice is not required to agree to my restrictions, but if it does, it is bound by this agreement. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting: Phone: 215-918-9310 Email: Katie.Killeen@ebsei.com 1500 S. Christopher Columbus Blvd., Floor 2, Philadelphia, PA 19147 Section B: Parent or Guardian Giving Consent (If Patient is not 18 years of age and their own guardian) Name: Relationship to Patient: Date: MM slash DD slash YYYY Right to Revoke: You will have the right to revoke this Consent at any time by giving written notice of your revocation submitted to EBS Children’s Institute, Attn: Clinical Director. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent. I have had full opportunity to read and consider the contents of this Consent and your Notice of Privacy Practices. I understand that, by signing at the end of this form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations. Child's Name: Date: MM slash DD slash YYYY Authorization for Recurring Credit Card ChargesFor your convenience, you may authorize recurring charges to your credit card to pay for your therapy sessions. You will be charged the day of your therapy appointment unless other arrangements have been made. The charge will be made under the name EBS Children’s Institute. You agree that no prior notification is necessary unless the amount billed each time exceeds the agreed upon amount below, in which case you will receive notification in advance. Name of Client:* Account Type:* Visa Mastercard American Express Discover Cardholder Name:* Credit Card Number:* Expiration Date:* CVV:* I authorize EBS Children’s Institute to charge this credit card for professional services and associated charges as agreed below. These charges may include:Co-pay and/or co-insurance for session: Self-pay for session or payment for session not covered due to deductible: Charge for cancellation without 24-hours notice: Other charges (specify): $ I understand that this authorization will remain in effect until I cancel in writing, and I agree to notify EBS Children’s Institute in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next bill date. * I agree to the above. SignatureBy my signature below, I acknowledge that I have read, understand, and agree to the following policies included in EBS Children’s Institute intake packet. Informed Consent Custodial/Court Documentation Acknowledgement Consent to Release/Obtain Information Health Policy Financial Policy Cancellation and Tardiness Policy HIPAA Notification Policy Authorization for Recurring Credit Card Charges I have been provided with the opportunity to ask any questions I have about the services to be provided as well as the other policies outlined in the documents listed above. I have also been provided with a copy of the documents. Child's Name: Date: MM slash DD slash YYYY
