Admission Form and Child Information 2024
Insurance Information (Commercial insurance or Medicaid)
I request that payment of authorized insurance benefits be made on my behalf to the provider for any medical services provided to me by that organization. I authorize the release of any medical or other information necessary to determine these benefits or the benefits payable for related equipment or services to the organization, my insurance carrier or other medical entity. A copy of this authorization will be sent to my insurance company or other entity if requested. The original will be kept on file by the organization.
I understand that I am financially responsible to the organization for any charges not covered by health care benefits. It is my responsibility to notify the organization of any changes in my health care coverage. In some cases, exact insurance benefits cannotbe determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill as determined by the organization and/or my health care insurer if the submitted claims or any part of them are denied for payment. I understand that by signing this form I am accepting financial responsibility as explained above for all payment for services received by the provider.
By signing this document, I also acknowledge that I am aware of the provider’s Notice of Privacy Practices. This acknowledgement is required by the Health Insurance Portability and Accountability Act (HIPAA) to ensure that I have been made aware of my privacy rights.
Your Signature *
Audio/Video Release Form
I hereby grant DH Therapy, LLC and DH Therapy Atlanta, LLC permission to take photographs and video tape recordings during the evaluation and/or treatment sessions at this facility or home/school setting. It is my understanding that DH Therapy, LLC and DH Therapy Atlanta, LLC and its students will not willfully release photographs and/or video recordings to an outside source without first obtaining parent/guardian written consent.
Your Signature *
Financial Policy
Insurance:
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Insurance will be billed at the usual and customary rate.
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We will need a copy of your valid insurance card (front and back).
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We are in network with Medicaid and several other insurance companies.
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If you do not have insurance or choose not to use it, you can pay the out-of- pocket rate listed below in “Out of Pocket Rates for Occupational, Speech, and Physical Therapy”.
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Please note that insurance is an agreement between you and your insurance company, benefits and payments are not always covered and payment will ultimately rest with the guardian.
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Co-pay – you are responsible for any co-pay at the time of visit.
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Co-insurance – you will be invoiced for your co-insurance once we receive the EOB.
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Deductible – you will be responsible for payment of your deductible, this amount will be stated on your EOB and invoiced once received.
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Please notify us immediately if there is a change in coverage.
Patient Information/HIPAA & Insurance Agreement
Out of Pocket Rates for Occupational, Speech, and Physical Therapy:
Out of pocket rate for children seen in our clinic 53-60 minutes is $150.
Out of pocket rate for home visit 53-60 minutes is $180.
Out of pocket rate for an evaluation and re-evaluation is $500.
No Pay:
Once you receive an invoice, payment is due within 7 days.
If payment is not received within 7 days a 10% interest charge to be added.
After three failed attempts to collect outstanding balance, your balance may be sent to a collection agency.
In certain cases a payment plan may be set up. Please ask if you qualify.
Attendance Policy
DH Therapy LLC is implementing an attendance policy to monitor and ensure that clients regularly attend their scheduled appointments for an overall successful therapy program. The policy states that clients may be removed from the schedule for any of the following reasons:
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Two missed or canceled appointments within a month (unless sickness or extenuating circumstances)
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Two no shows (missed appointments without a telephone call or prior notice within three months)
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Erratic and/or inconsistent behavior attendance (including late arrival for appointments)
All of the above may adversely affect your progress and success at therapy. In the event of any of the above reasons, clients may be removed from the schedule and placed on a wait list.
If you are removed from the schedule because of attendance problems, re-admission to therapy will require approval from the managerial team.
Punctuality for appointments allows adequate therapist/patient interaction and time to report outcomes to parents. If you are late, the session will need to conclude at theusual time to allow the therapist to stay on schedule.
A minimum of twenty-four (24) hours notice is requested for cancellations and rescheduling requests. We do understand that illnesses and emergencies happen suddenly and may require a last-minute notification.
Attendance when sick is NOT ENCOURAGED! In the best interests of your child, please try to reschedule their appointment if a cancellation is required. Please note that a Teletherapy session is highly encouraged when an in-office visit isnt feasible.
We cannot hold appointment time for those who cannot consistently attend. Similarly, we cannot reserve therapy time longer than two (2) weeks in case of extended absences unless there are extenuating circumstances.
Clinician Cancellations: If your clinician is not able to attend your appointment, you will be contacted as soon as possible. Please be sure that the office knows the best way to reach you. Every effort will be made to reschedule your appointment in a timely manner.
If your clinician is late for your appointment, you will be given the full session time. DH Therapy regrets any inconvenience to your personal schedule that this may cause. Your clinician will do their best to maintain timeliness.
Non-compliance with any portion of this attendance policy may result in termination of services.
I have read the above attendance policy and understand my cooperation and participation contributes to the success of my childs therapy program.
Parent's Signature *
Person who signs below is responsible for payment
Signature of Parent/Responsible Party *
Release or Obtain Medical Information
I authorize occupational, physical, and speech therapists and support staff of DH Therapy LLC and DH Therapy Atlanta, LLC consent to release any or all pertinent medical information to the referring physician and any additional physicians listed below to maintain quality of care. Furthermore, I authorize DH Therapy LLC DH Therapy Atlanta, LLC to release information to insurance providers to coordinate payment of benefits.
I understand that I have the right to revoke this authorization by written request at any time, except if the program or person, which is to make the disclosure, has already acted on it.
I understand that authorizing the disclosure of this health information is voluntary, and I do not need to sign this form in order “to be eligible for evaluation.” I understand that I have the right to copy and inspect the information to be disclosed. However, therapy treatment cannot be provided without disclosure. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules.
Release or Request of Medical Information
I acknowledge receipt of information and the Notice of Privacy Practices between DH Therapy LLC and DH Therapy Atlanta, LLC and the above name agencies/facilities and understand the conditions under which information will be used and disclosed. I understand the types of information that may be disclosed to the above-named persons.
This authorization will be in effect until discharge. I understand that I can add to or remove authorization of any person at any time in writing to DH Therapy LLC and DH Therapy Atlanta, LLC. I understand that I have the right to revoke this authorization by written request at any time, except if the program or person, which is to make the disclosure, has already acted on it. I understand that authorizing the disclosure of this health information is voluntary, and I do not need to sign this form in order to be eligible for evaluation. I understand that I have the right to copy and inspect the information to be disclosed. However, we will not be able to treat without disclosure. I understand that any disclosure of information carries with it the potential for an unauthorized re- disclosure and the information may not be protected by federal confidentiality rules. I give permission to release of information to the following:
Released records/information should be sent to: DH Therapy LLC, 7 Dunwoody Park, Suite 104, Atlanta, GA 30338
Parent's Signature *
We have received your details and one of our team members will be back in touch shortly.
Notice of Our Privacy Practices
In 1996, the Federal Government established uniform privacy and security standards to protect patients’ medical information. The standard is known as the Health Insurance Portability and Accountability Act (HIPAA). This notice takes effect April 14, 2003 and will remain in effect until we replace it. The purpose of this notice is to ensure that you (the health-care recipient) or your designated representatives are aware of your rights to ensure the privacy of your healthcare information. DH Therapy, LLC and DH Therapy Atlanta, LLC retains the right to update this notice at any time. To obtain the most recent notice, please submit a request in writing to the Office Manager of DH Therapy, LLC and DH Therapy Atlanta, LLC.
Privacy of the Patient Information
We have created a record of the services and treatment that you receive through DH Therapy, LLC and DH Therapy Atlanta, LLC The privacy of your medical information is important to us, and we are committed to protect it. We are required by law to keep your medical information private and notify you of your legal rights and privacy practices.
Uses and Disclosure of Patient Information
Your medical information will be used for treatment, payment, and operations to maintain the highest quality of care possible. HIPAA allows disclosure of this information to your designated/ authorized next of kin, licensed healthcare providers involved in your care and other healthcare entities including insurance companies, state and federal regulation and other agencies, as well as law enforcement agencies in the interest of public safety. If you are involved in a lawsuit or dispute, we may disclose medical information about you in response to a court or administrative order, subpoena, discovery request, or other lawful process. Any other uses and disclosures of your personal health information will be made only with your written authorization. You may revoke such authorization in writing, and we are required to honor and abide by that written request, except to the extent that we have already taken action relying on your authorization. You, the patient, however, reserve the right in writing restrictions on certain uses and disclosures.
Your rights regarding Medical Information About You
You have the right to inspect and copy your personal health information kept on file with DH Therapy, LLC and DH Therapy Atlanta, LLC. You have the right to amend information we have about you that is incorrect or incomplete. You have a right to request restrictions on the medical information we use or disclose about you for a treatment and payment. You have a right to an accounting of disclosures we made of medical information about you. All of the above request may be submitted in writing to the Office manager of DH Therapy, LLC and DH Therapy Atlanta, LLC at the address listed below.
Patient’s Access to Medical Information
You have the right to see and obtain a copy of your medical records at any time. You may request change in your health information and request the reason for any disclosure (not including treatment, payment, and healthcare procedures). If DH Therapy, LLC and DH Therapy Atlanta, LLC do not agree with your changes, you must be allowed to insert a statement of disagreement into the record. DH Therapy, LLC and DH Therapy Atlanta, LLC are not required to agree to your requested restrictions. However, if we agree, the restriction is binding.
Confidentiality of Patient Information
DH Therapy, LLC and DH Therapy Atlanta, LLC will attempt in all cases to preserve the confidentiality of all oral and written medical information. This includes progress information at the end of treatment sessions, written information and electronic transmission of information to physicians, insurance companies, state and federal entities, and law enforcement agencies in the interest of the public safety. DH Therapy, LLC and DH Therapy Atlanta, LLC will not be held responsible in the event of natural disaster, theft, or burglary of theft physical or electronic property, having taken reasonable precautions.
How to File a Complaint
You may file a complaint if you feel that your privacy rights have been violated. DH Therapy, LLC and DH Therapy Atlanta, LLC will not retaliate against you if you file a complaint. You may file a formal, written complaint with us at the address below, or with Department of Health & Human Services, Office of Civil Rights, in the event you feel your privacy rights have been violated.
For more information about HIPAA or to file a complaint:
The U. S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
(877) 696-6775
DH Therapy, LLC and DH Therapy Atlanta, LLC Contact Information
You may contact the DH Therapy, LLC. and DH Therapy Atlanta, LLC, for more information on our privacy policy at the below address, telephone number and email:
DH Therapy, LLC and DH Therapy Atlanta, LLC.
Address: 7 Dunwoody Park, Suite 104, Atlanta, GA 30338
(678) 616-1330
Email: Admin@DHTherapyAtlanta.com
Parent's / Guardian's Signature *