Danna Hunter

Patient Information Form contact info Patient Name ___________________________________________________ Date _________________ Address _______________________________________________________ DOB __________________ City _____________________ State____ Zip ___________ E-mail __________________________ Parent/Guardian Name___________________________________________________________________ Home Phone ____________________ Work ______________________ Cell_______________________ Pediatrician ________________________________________ Phone____________________________ PED’s Practice Name_______________________________________ Fax #: ______________________ Who may we thank for this referral? ______________________________________________________ Insurance Company______________________________________________________________________ I.D. # ___________________________________________ Group #: _______________________________ Policyholder: _____________________________________ Employer_______________________________ Policyholder’s DOB _______________________________ Authorization Required?_________________ Has deductible been met? YES_______ NO________ Copay Amount $_____________ and/ or _____________% I do not participate in Medicaid or Medicare_(sign)______________________________________________________ I do not have secondary insurance (sign)______________________________________________________________ General • • • • • • • Our Policies Payments for all professional services rendered are the responsibility of the patient regardless of insurance coverage. Payment: Payment is due at the time of service. Payment is accepted in cash or check. All balances are to be settled upon discharge. If not settled I give permission to Pediatric Feeding and Swallowing to charge my credit card for the remaining balance. I give my permission to allow Pediatric Feeding and Swallowing Associates to email any pertinent forms pertaining to my child via regular email. Medical Records: We will provide you a copy of your evaluations. If you need a copy of your entire chart, there is a medical record fee of $I0 or more depending on the size of the chart. There is no charge to send records to your pediatrician. To ensure HIPPA compliance, all records must be picked up from the office. Confidentiality: We are HIPPA compliant and take confidentiality seriously. All written reports or progress notes are provided to parents and the referring physician. We require a Release of Information form to be signed prior to releasing any information to or obtaining any information from any party or agency. These forms can be obtained from our office. We are HIPPA compliant. Waiting Room: Due to our patient’s high incidence of respiratory compromise and allergies, please refrain from wearing perfume or smoking directly before entering the office. There is no eating/drinking in the waiting area. 1 Patient Progress Policy • Given the medical and behavioral nature of pediatric dysphagia, it is your responsibility for your child to be seen per the treatment plan. Together, we cannot make progress without this, and insurers will not approve additional visits without documented progress. Cancellation Policy • Cancellations: Insurance companies are now strictly monitoring the number of therapy sessions attended vs scheduled and are refusing continued authorization or payment for patients with inconsistent attendance. • 24 HOUR CANCELLATION NOTICE: Aside from a medical emergency, if your scheduled session is not canceled with a minimum 24-hour advance notice or a make-up session is not scheduled the same calendar week, a $150 missed session charge will be charged to your account. This charge is not reimbursable by insurance and is automatically charged to your credit card. My credit card information is: Credit card number: Exp. Date: Security Code: Patients Paying with Insurance: • The patient is always ultimately responsible for payment. If payment has not been received from the insurer within a reasonable period of time, the patient will need to pay the full amount and work through any issues with the insurer directly. • PFS will: • File your insurance if we are in network or have explicitly agreed to do so. • Request information from your insurance provider regarding copay and deductible. • Insurance Authorization: I hereby authorize Pediatric Feeding and Swallowing Associates to furnish information to the insurance carriers concerning my evaluations and therapy and I hereby assign payment to Pediatric Feeding and Swallowing Associates for services rendered to my dependent. I understand that I am responsible for any amount not covered by my insurance. • We will assist you in any way possible with your insurance. However, it is ultimately your responsibility to understand your healthcare policy and its limitations. Your insurance is a contract between you and your insurance company. Authorization from your insurer does not guarantee payment by your insurer. BY SIGNING BELOW, I AGREE TO THE ABOVE POLICIES: Date: Guardian or Caregiver Signature: 2 Feeding/Dysphagia Evaluation Infant Questionnaire Please answer all questions that apply to your child Patient Name Date of Birth Date of Evaluation Parent/Guardian Names: Pediatric Group: Pediatrician: What, if any, diagnosis does your child have? Please list any medications your child is currently taking and the dosage per day: What are your goals for this evaluation? Does your child have a tongue or lip tie?______ Was it released? ____ When? _____ By whom? __________ Please check all concerns: Coughing/choking Congestion during feeding Reduce bottle dependence, transition to breast Short frequent feeding Uncoordinated suck swallow breathe Reflux or other GI issues Better breastfeeding Breastfeeding difficulty Milk coming out of nose Feeding stress Constipation Decrease tube feedings Biting instead of sucking Other: Nipple pain Feeding refusals Stressed feedings Weight gain Ankyloglossia Suck training Prenatal/Birth History: Was your child born full term? Yes ____ No ____; If no, how many weeks gestation? Vaginal birth___ C-Section___ Was labor/delivery difficult? ____Birth Weight ______ Birth Height Apgar Scores Did your child receive antibiotics at birth? Was your child in the NICU? Yes ____ No ____; If yes, why and for how long? Check all that apply to your child prior to discharge: feeds / Intubation / Oxygen / OG tube feeds / NG-tube Surgery (Please describe) Newborn hearing screening: Pass Fail General Medical History: Current medication:____________________________________________________________________ Has your child ever been hospitalized? _____; If yes, why? Please list any specialists that your child has seen:___________________________________________________ 3 Has your child had any of these procedures? EKG_________; EEG_________; MRI___________ Has a visual impairment Has an auditory impairment Sleeps through the night Takes good naps Maintains eye contact Holds own bottle Sensitive to touch Overly sensitive Tracks faces or objects Irritable Likes to swing Irritable (% of day Other:_______________________________________________________________________________________ ) What is your child’s current weight ________ weight percentile ________ height percentile ________ Is your child currently receiving any other therapies? ________ If yes, please list: Developmental/Sensory Processing History: My child: Bronchopulmonary and Otorhinolaryngeal History: Is your child congested? Never Sometimes Always When eating When drinking My child: Snores Audibly breathes at Audibly breathes audibly breathes has an open rest while sleeping during activity mouth posture Drools My child has/ had: Colds Bronchitis Pneumonia Respiratory infection Ear infection Diaper rash Thrush How many times has your child been treated with antibiotics? _______ Were they effective? Yes ____ No ____ Has your child had any problems with his/her tonsils or adenoids? ____ If yes, please explain: Gastrointestinal History: Has your child been diagnosed with gastroesophageal reflux? Yes ____ No ____; if yes, please list any reflux Is your child on reflux medications?(Please list)________________ Has any been discontinued?__________________ My child completed these procedures (include when and where) (please provide dates as possible): Upper GI -Ba Swallow Gastric emptying scan pH Probe Endoscopy Ultrasound MBS Does anyone in your family have a history of gastroesophageal reflux? Yes ____ No ____; if yes, please list relationship to child: Does your child spit up/vomit? Yes ____ No ____ Does it come out his/her nose? Yes ____ No ____ Do you feel like your child spits up more than most? Yes ____ No ____ How many times does your child typically spit up/vomit? per day ____ times per week? ____ When does s/he usually spit up/vomit? Can you predict when it will happen? Yes ____ No ____; If yes, how do you know? My child had any of the following physical and/or behavioral symptoms (please check all that apply): crying/fussing during or after feeds reduced appetite/limited intake grazing though out the day gagging/retching/coughing hiccupping/burping seeming desire to eat and then refuses eating small but frequent meals requiring distractions in order to eat Repeat swallows not associated with feeding arching 4 Are bowel movements are normal? Yes ____ No ____ How many per day? ______ What color?______________ Does/Did your child suffer from constipation? Yes ____ No ____, diarrhea? Yes ____ No ____ Have you or do you stimulate a bowel movement with: Diet Medication Suppositories Thermometer Allergies and Food Intolerances: Has your child ever had allergy testing? Yes ____ No ____; If yes, results: Does your child have a clinical diagnosis of any food or environmental allergies? Yes ____ No ____ If no, do you suspect any allergies? Yes ____ No ____; If yes, please list: Is your child allergic to latex? Yes ____ No ____ Has your child had eczema? Yes ___ No ___; rashes? Yes __ No __; yeast infections? Yes ____ No ____ Does anyone in your family have allergies or food intolerances? Yes ____ No ____; If yes, please list relationship to child and what they are allergic to: Feeding History: How is your child currently fed? Breast___ ; Bottle___; SNS____; NG Tube ___; G-Tube___; Puree; ___ Other Was your child breastfed? Yes ____ No ____; If yes, for how long? If breast feeding was discontinued, please check why: Difficulty latching on ______ Personal preference ______ Weight gain issues (baby) ______ Return to work ______ Anatomical anomaly ______ Other Is/was your child on formula? Yes ____ No ____ Current formula Have you switched formulas? Yes ____ No ____ List all formulas tried and why they were changed: Are you thickening the liquids? Yes ___ No___ Are you using rice cereal? Yes___ No ___ How much?_______ What is the name of the nipple/bottle you are using/used? Have you switched bottle nipples? Yes ____ No ____; If yes, why? Does your child choke____ ; cough____; gag ____; vomit _____ during feeding?_____ After feeding?________ Please describe: Does your child indicate hunger? Yes ____ No ____ Does your child like to eat? Yes ____ No ____ Have you introduced spoon feeding? Yes___ No ___ Was it easy? Yes___ No____ Do you feel stressed regarding your child’s feeding? Yes ____ No ____; If yes, why? Have you ever forced your child to eat? Yes ___ No ___ , Has forcing ever resulted in vomiting? Yes___ No ___ Do you feel your child takes in adequate nutrition? Yes ___ No ___ Is your doctor concerned about your child’s weight gain ? Yes ____ No ____ Are you worried about your child’s weight gain? Yes ___ No ___ How many ounces does your child take per feeding?_______ per 24 hours?__________ How often does your child eat?_____________How long does feeding take?_________________________________ 5 Consent To Release Information This Consent to Release Information is HIPAA compliant. It is intended for the person/persons it is addressed to. If you receive this in error, please shred all copies and discard or return to this office. Patient Name_______________________________________________Date of Birth________________________ I ______________________________ hereby give permission to Pediatric Feeding and Swallowing Associates to obtain and release any and all information about my child concerning his/her care, treatment, evaluation, or billing, pertaining to his/her treatment for the purpose of continuity of care. To/From: _______________________________address_____________________phone#___________ Physician or Healthcare Provider _______________________________address_____________________phone#___________ Physician or Healthcare Provider _______________________________address_____________________phone#___________ Physician or Healthcare Provider _______________________________address_____________________phone#___________ Physician or Healthcare Provider I give permission for my therapist at xxxxxxxxxxxx to leave medical information or appointment reminders on my (please check all that apply): Voicemail (best #)______________ Email (best address)_____________________ Text (best #)__________________ _______________________________________ Parent/Guardian’s Signature ________________ Date _______________________________________ Witness ________________ Date 6 Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Effective Date: April 14, 2003 Our Pledge Regarding Your Child’s Privacy: We understand that medical information about your child and their health is personal. We are committed to protecting the confidentiality and privacy of your child’s protected health information. We are required to abide by the terms of the notice currently in effect and when changes are made, a new Notice of Privacy Practice will be distributed. How We Will Use or Disclose Your Child’s Health Information: COMPANY uses your child’s protected health information for treatment, obtaining payment for treatment and conducting its healthcare operations. For example, COMPANY will use your child’s medical information to perform requested consults or treatment services and provide your child’s referring physicians with a report of our findings. We may share your child’s protected health information (PHI) with your insurance company, our billing department and collection agencies. We will only use or disclose your child’s private health information in accordance with applicable state and federal laws. COMPANY may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits. COMPANY may use or disclose your child’s protected health information without authorization for auditing purposes, public health purposes, and for emergency situations. For any other situation, Carolina Pediatric Dysphagia’s policy is to obtain your written authorization before disclosing your protected health information. Once authorization is obtained, you may later revoke that authorization to stop any future disclosure. Patient’s Individual Rights: You have the right to request to receive, inspect, amend and request restrictions on certain uses and disclosures of protected health information (PHI). You also have the right to request in writing, an accounting of disclosures of your child’s protected health information for reasons other than treatment, payment, or other healthcare operations. You also may request in writing that COMPANY not use or disclose your child’s protected health information for treatment, payment and administrative purposes when required by law or in an emergency situation. COMPANY will review the request on an individual basis, but we are not legally required to accept it. For More Information or to Report a Problem: If you believe that COMPANY may have violated your child’s privacy rights, you may file a complaint with us. These complaints must be filed in writing on a form provided by our practice. You may also file a written complaint with the Secretary of the Federal Department of Health and Human Services. There will be no retaliation for filing a complaint. For further information, you may contact our Privacy Officer at (xxx) 2xxxxx3 I acknowledge receipt of Pediatric Feeding and Swallowing Associates’ Notice of Private Practices. ____________________________________________________ Print Child’s Name ____________________________________________________ Guardian’s Signature ___________________ Date ____________________________________________________ Witness ___________________ Date 7