615 East Princeton Street, Suite 300 Orlando, Florida 32803 Phone: 407-898-6005 Fax: 407-898-7722 WELCOME TO OUR PRACTICE Thank you for allowing us the opportunity to serve you and your family’s needs. The Center for Child Development provides comprehensive multidisciplinary care to children with developmental, behavioral, social and academic needs. We are committed to delivering preeminent personalized services for children, adolescents and their families. A thorough history and physical exam is done during the first visit and when indicated, testing is completed at the second visit. Our mission is to improve children’s lives by helping them to achieve their best potential. In order for us to provide the quality of care that you expect and deserve please take a moment to review the following important information in regards to your appointment request. Appointment Date:
Appointment Time:
Patient Advocate:
Patient Phone:
Insurance Carrier:
Policy Number:
Please bring the following information to the appointment: ! Picture ID ! Insurance Card ! Referral from your primary care physician or whomever referred you to our practice ! Co-Pay/Co-Insurance – as a courtesy we will bill your insurance company and collect your copayment or deductible on the day of your visit. ! Patient Information Forms – please complete the enclosed patient information forms which are needed to assist us in the evaluation of your child. They can be returned to us via fax at 407-898-7722 or mail to the address above. Your child’s appointment may be shorter if you have not completed all of your paperwork before your scheduled appointment time. ! Copies of previous medical records if available ! Copies of previous evaluations, school reports, report cards, IEPs, teachers' reports and/or standardized test results: Cognitive (IQ), Achievement, Adaptive, etc. ! Please bring the teachers’ Vanderbilt behavior form completed if your child is older than 4 years.
Revised October 2013
Helpful Information Arriving to the appointment: Please plan to arrive 20 minutes before your scheduled appointment to allow us the time to register your child appropriately, collect your co-pay and update any changes to your insurance information, address or other contact information. • Co-payments are collected at the time of service. • You may have questions to fill out at each visit. Appointments and Cancellations: All services are by appointment only. We understand emergency situation arise and you may need to reschedule or cancel an appointment. If you are unable to keep your scheduled appointment please call 407-898-6005, we request a 24-hour cancellation notice if you are not able to attend a scheduled appointment. • A $25.00 fee will automatically be charged if you cancel your follow-up appointment with less than a 24-hour notice or no-show to your follow-up appointment. • A $50.00 fee will automatically be charged if you cancel your testing appointment with less than a 24-hour notice or no-show to your testing appointment. • Your insurance company will not cover this charge. • After 3 missed or canceled appointments, you may be discharged from our care. Late Policy: • If you are going to be more than 10 minutes late for your scheduled appointment time, we request that you call our office at 407-898-6005. We will do everything possible to accommodate the delay schedule permitting, though there may be times where we cannot accommodate the delay due to previously scheduled patient appointments and we may need to reschedule or modify your appointment. We work diligently to stay on schedule and ask that you arrive 20 minutes prior to your scheduled appointment to allow time for any necessary paperwork. Prescription Refill: • The Center for Child Development will not be able to provide your child with medication refills if you child has not been seen at their regularly scheduled appointments. • We require 2 business days notice to process all prescription refills, it may take up to 72 hours before it is mailed out. • For non controlled substance refills, please ask your pharmacy to fax a refill request to our office at 407-898-7722. Provider Phone Calls: • Our staff will respond to all calls within 24 hours on business days, excluding holidays. • If you are in an emergency situation please call 911 or go directly to the nearest emergency room. Insurance and Billing: Our office will bill your insurance as a courtesy for all participating insurance plans. We advise our patients to check with their insurance provider prior to their appointment to ensure the visit will be covered. • Payment is expected when services are rendered. • Your co-payment or co-insurance is to be paid on the day of your visit. Copies of Records: In general, the confidentiality of all communications between a patient and a health care provider are protected by law. Consequently, records of the services provided to your child can only be released with your written permission and we will provide a release of information form for you to sign. • Please let us know if you would like a copy of your child’s medical records sent directly to you there is a fee of $1.00 per page. Payment is required prior to the release of records. • When records are sent to another provider for continuity of care we will send this at no charge. Letters: There is no charge for the original diagnosis letter. • There is a $25.00 charge for detailed letters or forms, i.e. FMLA
Revised October 2013
615 East Princeton Street, Suite 300 Orlando, Florida 32803 Phone: 407-898-6005 Fax: 407-898-7722
I
have received the FHMG Center for Child Development
“Welcome To Our Practice” packet. I have read the packet or have had it read to me. I understand the following information provided and it is my responsibility to supply, review and/or complete:
•
Patient Information Forms
•
Previous Evaluation Forms
•
Arriving to Appointments
•
No Show / Cancellation Fee
•
Late Policy
•
Prescription Refills
•
Provider/Emergency Calls
•
Insurance and Billing
•
Co-Payments / Co-Insurance
•
Medical Records Release
•
Letters
Patient Name
Date
Patient or Parent/Guardian Signature
Date
FHMG Center for Child Development Staff
Date
Revised October 2013
Center for Child Development Intake Questionnaire
Childs Name: County of Residence: Allergies: Child’s Primary Care Doctor: Who suggested this evaluation? Primary concerns? PRESENTING HISTORY
DOB:
Age:
Phone #:
Name of person completing this form: Describe your concerns about your child? Please describe your child: What treatment options are you considering? If medication is suggested as a part of your child’s evaluation, are you willing to consider it? ! YES ! NO BIRTH HISTORY
Pregnancy: ! Diabetes ! Seizures ! Hypertension ! Preeclampsia During pregnancy, any: ! Tobacco use ! Alcohol use ! Prescription drugs Describe: 1 Rev 07/14
Delivery:
! Cesarean section OR ! Vaginal delivery Was birth on time? ! YES ! NO # of weeks early: # of weeks late: Mother’s age at time of delivery: prenatal care: ! Yes ! NO Did child require resuscitation: ! Yes ! NO Birth weight: Other Neonatal:
Did child stay in special nursery or NICU? ! Yes ! NO how long? Did child have: ! Respiratory distress ! Feeding problems ! Hemorrhage ! Seizure ! Low Muscle Tone ! Jaundice Other Did child require: ! Ventilator ! CPAP ! Oxygen ! Tube feeding ! Phototherapy Passed newborn hearing screen: ! Yes ! No Florida newborn screening results: ! Normal ! Abnormal Age at hospital discharge: months weeks days PAST MEDICAL CARE
Medical care that your child is currently receiving from any other providers: Doctor Name Specialty Is your child currently being seen by a psychiatrist? ! YES ! NO Has your child ever been evaluated by a psychiatrist? ! YES ! NO Has your child ever been admitted to a mental health facility? ! YES ! NO Therapies: ! speech ! OT ! PT Receiving therapy at: ! school ! home Prior medical diagnosis that your child has/had? Diet history (regular for age?): Immunizations up to date? ! Yes ! NO Which are delayed? Why __________ Any hearing or vision concerns? 2
SURGICAL HISTORY
Previous surgeries or hospitalizations? MEDICATIONS
Any prior medications? Any current medications? Has your child ever had: ! EEG ! Brain MRI ! genetic testing ! metabolic testing Were any of the results abnormal? ! YES or ! NO Which test/s? DEVELOPMENTAL HISTORY
Infant: Child took solids well?
! Yes ! No
Child babbled at 6 months (BaBaBaBa, DaDaDa, GuGuGu)? ! Yes ! No Child sat independently at
months, child pulled to stand at
Child babbled DaDa specifically for father at
months.
months, MaMa for mother at
months.
Toddler: Child walked at
Child used two word phrases at
months
months
Has toilet training been attempted? ! Yes ! No At what age did child?
Write in age below:
Hold up head
Roll over
Gross motor delay?
! Yes ! No
Sit unsupported
Fine motor issues?
! Yes ! No
Stand alone
Sensory issues?
! Yes ! No
Walk
All milestones on time?
! Yes ! No
Talk
Toilet train
Speech / Language delay?
Feed him/herself
Dress him/herself
3
! Yes ! No
EDUCATIONAL HISTORY
Current School or Daycare: County: Grade: Type of class: ! Mainstream ! ESE ! ASD ! EBD ! Other: Any pull out or resource services: Has your child ever been home schooled: ! Yes or ! NO which grade/s: Has your child ever repeated a grade: ! Yes or ! NO which grade/s: Does your child have a: ! RTI ! 504 ! IEP What are the components of the IEP/504 plan? SCHOOL HISTORY Previous School Age(s) Grade Class Type Academic or Behavioral Concerns (Regular,ESE,ASD,EBD)
Services at School How Frequently? How long/sessions Individual or Group Speech Therapy Occupational Therapy Physical Therapy Social Skills SOCIAL HISTORY Are your child’s parents: Married Single Separated Divorced Date of divorce or separation: /______/______ Lives with: ! mother ! father ! step mother ! step father 50/50 other:_________________ Custody Arrangements: Are there any custodial issues?
4
FAMILY HISTORY
MOTHER
Natural/ Adoptive/ Guardian (circle one)
FATHER
Natural/ Adoptive/ Guardian (circle one)
Name:
Name:
Age:
Age:
Occupation:
Occupation:
Employer:
Employer:
Education Level:
Education Level:
STEP MOTHER
STEP FATHER
Name:
Name:
Age
Age
Occupation
Occupation
Employer:
Employer:
Education Level:
Education Level:
Siblings Name(s)
Age
How Related
Grade Medical problems
Behavior problems/ Academic problems/ Developmental problems
5
Medical Condition
Mom
Dad
Sister
Brother
Mom’s Mom
Mom’s Dad
Dad’s Mom
Dad’s Dad
Heart Disease
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Diabetes
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Hearing Problems (not from old age)
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Stroke: Hypertension
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Arrhythmias or prolonged QT syndrome
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Seizures
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Thyroid
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School problems
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Developmental Delay
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Learning Disabilities
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ADHD/ADD
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Autistic Spectrum Disorder
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Mental Retardation
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Depression
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Alcoholism
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Anxiety
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Bipolar/Mood difficulties
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Suicide
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Other:_______________
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Is there any chance the natural mother and natural father are related outside marriage? ! Yes ! No Additional stressors include:
6
REVIEW OF SYSTEMS SCHOOL ! Reading problems ! Poor concentration ! Learning problems ! Underachievement ! Boredom ! Afraid of School ! Cannot follow directions ! Handwriting difficulties RELATIONSHIPS ! Clinging ! Demanding ! Dislikes mother ! Dislikes father ! Jealous of brother/sister ! Shy ! Dislikes self ! Bossy ! Ignores others ! Aggression towards family ! Does not get along with teachers ! Difficulty making and keeping friends EMOTIONS ! Sad or depressed ! Angry ! Fearful ! Withdrawn ! Over-‐anxious ! Unhappy ! Sullen ! Cries easily ! Sensitive ! Daydreams ! Imagines things ! Bad dreams or nightmares ! Hallucinations ! Loses temper ! Preoccupied ! Humorless ! Flat affect
BEHAVIOR ! Poor sense of right and wrong ! Fights ! Cheats ! Steals ! Lies ! Tantrums ! Destructive ! Skips school ! Mean to other children ! Sets fires ! Runs away ! Rages ! Quarreling ! Rebellious ! Classroom behavior problem ! Lacks initiative ! Accident prone ! Overactive ! Lazy ! Blames others ! Wanders off ! Unreliable ! Irresponsible ! Easily frustrated ! Unpredictable ! Cruel to animals ! Perseveration ! Short attention span ! Compulsive ! Immature ! Manipulates DEVELOPMENT ! Health problems ! Poor coordination/ clumsiness ! Speech problems ! Delayed development ! Physical handicap 7
HABITS ! Bed-‐wetting ! Chewing clothes ! Mouthing objects ! Soiling ! Eating problems ! Nail-‐biting ! Thumb sucking ! Hair pulling ! Tics, twitching, blinking ! Head banging ! Rituals ! Obsessive cleanliness ! Rocking ! Headaches MEDICAL ! Excessive weight loss ! Excessive weight gain ! Staring spells ! Involuntary movements ! Vocal tics ! Motor tics ! Headaches ! Hypotonia ! Been tested for glasses ! Lazy eye ! History of allergies ! Feeding difficulties ! Frequent gagging/choking ! Physical complaints ! Stuttering ! Eating non-‐food items ! Heart murmur ! Heart palpitations ! Chronic constipation ! Birth marks ! Nightmares ! Night terrors ! Sleep walking/talking ! Trouble getting to sleep ! Trouble staying asleep
Consent to Release of Health Care Information I acknowledge that I have received a copy of the Practice’s Notice of Patient Privacy practices, which describes the permitted uses and disclosures of my health care information related to my care by the Practice, and payment of my charges for the services received at the Practice. I specifically authorize the uses and disclosures of my health care information described in the Practice’s Notice of Patient Privacy Practices. I consent to release of my health care information, including but not limited to medical, psychiatric, substance abuse or HIV information, for: (1) medical purposes, including but not limited to treatment, prescriptions, and other care coordination purposes; or (2) payment purposes to third parties including but not limited to federal or state health plans, insurance companies, collection agencies, employers or other organization responsible for payment of my charges for the services received at the Practice, EXCEPT: !
!
None
(Please initial)
(Please specify)
I consent to the Practice taking and reproducing pictures (regardless of medium [e.g. photograph, film, tape, etc.]) of me in connection with my diagnosis, care and treatment (including surgical procedures) for use in association with treatment, scientific and educational purposes, and/or Practice department functions (e.g., performance improvements, etc.). THE UNDERSIGNED MAY RECEIVE A COY OF THIS RELEASE UPON REQUEST, AND CERTIFIES THAT HE OR SHE HAS READ THIS RELEASE AND HAS BEEN ABLE TO ASK QUESTIONS.
Printed Name of Patient Patient’s Signature & Date Printed Name of Legal Representative/Principal Obligor Relationship to Patient (Self, Legal Representative, Principal Obligator, General Agent)
Printed Name of Witness
Witness’ Signature & Date
Legal Representative/Principal Obligor’s Signature & Date Printed Name of Interpreter [if applicable]
IF THE PATIENT, PRINCIPAL OBLIGOR, LEGAL REPRESNTATIVE, OR GENERAL AGENT IS ONLY ABLE TO GIVE VERBAL CONSENT AS AN EMPLOYEE OF THE PRACTICE I HAVE SIGNED THIS FORM ON BEHALF OF THE PATIENT TO ACKNOWLEDGE THE VERBAL CONSENT BY THE PATIENT OR THE PATIENT’S PRINCIPAL OBLIGOR, LEGAL REPRESENTATIVE, OR GENERAL AGENT, TO THE PROVISION OF TREATMENT BY THE PRACTICE. Printed Name of Patient Printed Name of Individual Providing Verbal Consent Printed Name of Hospital Employee Practice Employees’ Signature & Date
Reason Verbal Consent Obtained
Relationship to Patient (Self, Principal Obligor, Legal Representative or General Agent
Printed Name of Witness
Witness’ Signature & Date
PK5510 Back (09/11)
COMMUNICATION USE AND DISCLOSURE AUTHORIZATION Section A: Please complete the following information for all requests
1.
Today’s date:
2.
Patient name:
3.
Date of Birth:
4. Patient #:
5. Address:
I hereby request the following regarding the use of my PERSONAL HEALTH INFORMATION: 1. You may leave the following messages on answering machines: ☐ Referral Information
☐ Prescription refill information
☐ Test results
☐ Other:
2.
3.
You may discuss information regarding my treatment and care with the following family members and/or friends:
You may contact me regarding my treatment and care at the following numbers:
Signature of Patient or Guardian
Signature of Staff Person and Title
Printed Name of Staff Person and Title
Date
PK5510 Back (09/11)
AUTHORIZATION FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION (MEDICAL RECORD) PLEASE COMPLETE ALL FIELDS SECTION A: Must be completed for ALL Authorizations
By signing this Authorization, I hereby authorize and permit the use and/or disclosure of my protected health information (medical record) for the limited purpose(s), and in the limited manner, described in this form. In addition, I understand that this Authorization is completely voluntary and I am signing it under my own free will. Patient Name:
Patient #:
Home Address:
Date of Birth:
Persons/organization providing the information: (Complete w/Address)
Center for Child Development, 615 E. Princeton Street, Suite 300, Orlando, FL 32803 407-‐898-‐6005 fax 407-‐898-‐7722
Persons/organizations receiving this information: (Complete w/Address)
Specific description of information (including date(s)) to be used and/or disclosed about me: * The following items must be initialed to be included in the use or disclosure of other health information: *HIV/AIDS related health information and/or records. *Mental health information and/or records. *Genetic testing information and/or records. *Drug/alcohol diagnosis, treatment and/or referral information (Federal regulations require a description of how much and what kind of information is to be disclosed. Federal law prohibits the disclosure of such information.)
SECTION B: Must be completed only if FHMG has requested the Authorization 1. FHMG must complete the following:
a.
What is the purpose of the use or disclosure? (check one) At the patient’s (or the patient’s representative’s) request or direction For marketing. For fundraising. Other (describe):
b.
Will the FHMG practice requesting the Authorization, receive financial or in-‐kind compensation, directly or indirectly, in exchange for using or disclosing the health information described above? Yes No
PK5510 Back (09/11)
2. The patient or the patient’s representative must read and initial the following statements: a. I understand that my health care and the payment for my health care will NOT be affected if Initial:
b.
I DO NOT sign this form. I understand that I may see and copy the information described on this form if I ask for it, and that Initial: I get a copy of this form after I sign it.
SECTION C : Must be completed for ALL Authorizations
The patient or the patient’s representative must read and Initial the following statements: I understand that this Authorization will expire. (Please choose 1 of the 3 options listed below): a. No expiration (permitted only for Authorizations used to create or maintain research Initial: databases or repositories). b. On (DD/MM/YYYY) Initial: c. When the following event occurs Initial: Signature of Patient or Patient’s Representative Date (Form MUST be completed before signing) Print Name of Patient’s Representative:
Relationship to the Patient:
Reason Authorization is signed by the Patient’s Representative: (Check one) Minor Incompetent Other (Explain)
* YOU MAY REFUSE TO SIGN THIS AUTHORIZATION *lf this Authorization form authorizes use and/or disclosure of psychotherapy notes, it may not be used to authorize the use and/or disclosure of any other protected health information. A separate Authorization form is needed for any other use and/or disclosure.
PK5510 Back (09/11)