Sunshine Pediatric Therapy, LLC
5 Ivy Lawn Place . Greenville, SC 29605
770-256-9921 (Phone) . 404-596-5433 (Fax)
www.sptherapy.com
REGISTRATION INFORMATION:
PATIENT NAME: ____________________________________________ DATE OF BIRTH: _____________________________
PARENT/ GUARDIAN NAME(S): ____________________________________________________________________________
HOME ADDRESS: ________________________________________________________________________________________
HOME PHONE: _______________________________________ CELL PHONE: ______________________________________
EMAIL ADDRESS: ________________________________________________________________________________________
BEST WAY TO CONTACT YOU? ____________________________________________________________________________
REFERRING PHYSICIAN: __________________________________________________________________________________
DIAGNOSIS: ________________________________________ EMPLOYER: ________________________________________
Does your child participate in the GA BCW program? (If yes, please include county and service coordinator name/ number):
_________________________________________________________________________________________________________
Is your child enrolled in Atlanta Public Schools?: __________ If yes, please note that you may be required to submit a copy of your
child’s IEP to Sunshine Pediatric Therapy on an annual basis.
PRIMARY INSURANCE: ___________________________________________________________________________________
POLICY HOLDER: ______________________________________________DATE OF BIRTH: _____________________________
POLICY NUMBER: _____________________________________________GROUP NUMBER: ___________________________
MEMBER SERVICES PHONE NUMBER: ______________________________________________________________________
SECONDARY INSURANCE: _________________________________________________________________________________
POLICY HOLDER: ______________________________________________DATE OF BIRTH: _____________________________
POLICY NUMBER: _____________________________________________GROUP NUMBER: ___________________________
MEMBER SERVICES PHONE NUMBER: _______________________________________________________________________
CONSENT FOR TREATMENT/ RELEASE OF INFORMATION:
I, ___________________________, hereby authorize Sunshine Pediatric Therapy, LLC to provide physical, occupational, and/or speech
therapy services for ____________________. I understand that it is my responsibility to be present for each treatment session. I also authorize
Sunshine Pediatric Therapy, LLC to obtain necessary medical documents and release therapy evaluations and progress notes to all physicians,
therapists and service coordinators providing services for my child.
Parent/ Guardian Signature: __________________________________________ Date: _____________________
Helping Children Grow
1
Sunshine Pediatric Therapy, LLC
5 Ivy Lawn Place . Greenville, SC 29605
770-256-9921 (Phone) . 404-596-5433 (Fax)
www.sptherapy.com
POLICIES AND PROCEDURES
Sunshine Pediatric Therapy, LLC
Effective January 1, 2014
Thank you for choosing Sunshine Pediatric Therapy, LLC. The following information details current billing, financial, attendance and sickness
policies. Please read carefully and sign/ initial where indicated.
Financial Policy:
All primary insurance is accepted. Sunshine Pediatric Therapy, LLC is out-of-network with all insurance providers.
Sunshine Pediatric Therapy, LLC will bill your primary insurance company as a service to you; note that claims will be submitted from Sunshine
Pediatric Therapy, LLC as an out-of-network provider for all insurance companies with the exception of BCBS. Because individual insurance
plans vary, please review your benefits for physical, occupational and/or speech therapy services for detailed information regarding coverage.
Note that information obtained from insurance companies when verifying benefits is not a guarantee of payment; therefore, it is imperative that
you understand your coverage and what out-of-pocket expenses you may incur.
I understand that payment must be received no more than 45 days following the date of claim submission; if payment has not been received, I
understand that I will receive an invoice for the outstanding date(s) of service and agree to pay the balance in full by the payment due date.
____________ parent initials
Katie Beckett Deeming Waiver and SSI Medicaid are accepted. Medicaid funded CMO’s (including PeachState, Amerigroup and WellCare) are
NOT accepted. Your primary insurance will be billed first and Medicaid will be billed as a secondary payment source unless it is the primary
insurance for the patient. Note that Medicaid has changed their policy (effective 1/1/10) regarding the use of an out-of-network provider for
services rendered; as taken from the Part I Policies & Procedures/Billing manual, ‘…when the primary health plan has in-network and out-ofnetwork providers and the member has chosen to seek care from an ‘out-of-network’ provider for a service that is fully covered by an ‘in-network’
provider, Georgia Department of Community Health will not pay this claim as primary and no reimbursement will be processed to the provider for
these services.’
I understand that I am responsible for all claims submitted by Sunshine Pediatric Therapy, LLC that have been denied by my primary insurance
company and/or Medicaid for any reason. I understand that I may receive an invoice for the outstanding date(s) of service and agree to pay the
balance in full by the payment due date.
____________ parent initials
Prior approvals will be required for therapy services over eight units per month (approximately two therapy sessions); the treating therapist
agrees to submit necessary prior approvals.
For patients who do not have Medicaid coverage, parents will be responsible for the full amount of any treatment session that is applied toward
meeting the patient’s medical deductible for the primary insurance carrier.
____________ parent initials
Initial and annual evaluations are considered a billable fee for service expense. A full, typewritten report will be completed upon parent request
only and will be billed accordingly to the requesting parent/ caregiver. Note that Individualized Education Plans (for children over the age of
three enrolled in the Atlanta Public School system) must be completed on an annual basis and are an adequate substitute for a detailed therapy
evaluation. Progress notes and letters of medical necessity will be provided free of charge upon request of the parent and/or service coordinator
(if applicable).
I understand that all therapy evaluations will be billed to me and are provided upon request only. Detailed therapy assessments are not billed to
my insurance company.
____________ parent initials
I authorize the release of any insurance information necessary to process claims. I authorize the payment of insurance claims to be released to
Sunshine Pediatric Therapy, LLC. I understand that I am financially responsible for all claims not paid by insurance for services provided by
Sunshine Pediatric Therapy, LLC. I understand that therapy services will be put on hold or terminated if payment is not received by the payment
due date indicated on the invoice for treatment.
____________ parent initials
Helping Children Grow
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Sunshine Pediatric Therapy, LLC
5 Ivy Lawn Place . Greenville, SC 29605
770-256-9921 (Phone) . 404-596-5433 (Fax)
www.sptherapy.com
If insurance payments are sent to the member (parent/ caregiver) rather than the provider, Sunshine Pediatric Therapy, LLC, I understand that I
am responsible for sending a check for the full amount of reimbursement to Sunshine Pediatric Therapy Services, LLC within one week of
receiving the insurance payment. I understand that therapy services will be put on hold if payment has not been received.
____________ parent initials
Sunshine Pediatric Therapy, LLC has the right to suspend or terminate therapy services to any child in the company’s sole judgment upon
noncompliance of any of these policies by any parent, or as necessary while payment questions are resolved between a family and their
insurance provider. Furthermore, Sunshine Pediatric Therapy, LLC has the right to take appropriate steps to procure payment from a parent in
situations where a parent is responsible for all or part of unpaid invoices.
____________ parent initials
Privacy Policy:
I have read and signed the accompanying HIPPA policy concerning the release of my child’s medical information and insurance information.
____________ parent initials
Fee Schedule:
Invoices for payment are sent out via US mail to families (when applicable) no later than the 5th day of the month following the service month.
Please contact our business manager, John North at johnrnorth@hotmail.com, with any questions related to billing or financial policy.
Attendance Policy:
Sunshine Pediatric Therapy Services, LLC requires a 24-hour cancellation notice. If you fail to give this notice, a cancellation fee of $25 will
be charged to your account (there will be a one time warning prior to your account being charged). We understand that emergency situations
will occur and this will be handled on a case by case basis.
If three consecutive weeks of therapy are missed, the treatment slot will be given to another child and a new time slot will need to be arranged
with your treating therapist. If a patient does not show up for a therapy session, it is up to the therapist’s individual discretion whether or not to
continue treating the child.
____________ parent initials
Sickness Policy:
The Board of Health considers the following signs/symptoms to indicate the presence of a communicable disease or illness:
Vomiting
Diarrhea
Rash/Swelling
Fever over 100 degrees
Sore throat
Red, runny eyes
All treating therapists work with medically fragile children and it is our goal to avoid carrying illnesses to these children or infect ourselves or our
own families. Please be respectful and use discretion when deciding whether or not to cancel your scheduled therapy appointment if your child
is sick. In addition, please be sure your child is symptom free for 24 hours before resuming therapy.
____________ parent initials
Thank you.
Parent/Guardian Signature: ___________________________________________
Helping Children Grow
Date: ___________________
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Sunshine Pediatric Therapy, LLC
5 Ivy Lawn Place . Greenville, SC 29605
770-256-9921 (Phone) . 404-596-5433 (Fax)
www.sptherapy.com
NOTICE OF PRIVACY PRACTICES
Notice of Privacy Practices
(effective September 23, 2013)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
We understand the importance of privacy and are committed to maintaining the confidentiality of your Medical Information. 1 This Notice
describes how we may use and disclose your Medical Information. It also describes your rights and our legal obligations with respect to your
Medical Information. We make a record of your Medical Information regarding the medical care we provide and may receive such records from
others. We use your Medical Information records to provide or enable other health care providers to provide quality medical care, to obtain
payment for services provided to you as allowed by your health plan, and to enable us to meet our professional and legal obligations to operate
Sunshine Pediatric properly. We are required by Applicable Law2 to maintain the privacy of your Medical Information, to provide individuals with
notice of our legal duties and privacy practices with respect to protected Medical Information, and abide by the terms of this Notice. If you have
any questions about this Notice, please contact our contact person listed above.
A.
How We May Use or Disclose Your Medical Information
Sunshine Pediatric Therapy, LLC (“Sunshine Pediatric”) collects Medical Information about you and stores it in a chart and on a computer. This
is your medical record. The medical record is the property of Sunshine Pediatric, but the Medical Information in the medical record belongs to
you. Applicable Law permits or requires us to use or disclose your Medical Information for the following purposes:
1.
Treatment. We use Medical Information about you to provide your medical care. We disclose Medical Information to our employees and
others who are involved in providing the care you need. For example, we may share your Medical Information with other physicians or
other health care providers who will provide services that we do not provide. We may also disclose Medical Information to members of
your family or others who can help you when you are sick or injured, or after you die.
2.
Payment. We use and disclose Medical Information about you to obtain payment for the services we provide. For example, we may give
your health plan the Medical Information it requires before it will pay us.
3.
Health Care Operations. We may use and disclose Medical Information about you to operate. For example, we may use and disclose
Medical Information to review and improve the quality of care we provide, or the competence and qualifications of our professional staff.
4.
Sign In Sheet/Appointment Reminders. We may use and disclose identifying information about you by having you sign in when you arrive
at our office or when we call you for appointment reminders.
5.
Public Health, Health Oversight Activities & Public Safety. We may, and are sometimes required by Applicable Law, to disclose your
Medical Information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting
child, elder or dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems
with products and reactions to medications; and reporting disease or infection exposure. We may, and are sometimes required by
Applicable Law, to disclose your Medical Information to health oversight agencies during the course of audits, investigations, inspections,
licensure and other proceedings, subject to the limitations imposed by Applicable Law. We also may, and are sometimes required by
Applicable Law, to disclose your Medical Information to appropriate persons in order to prevent or lessen a serious and imminent threat to
the health or safety of a particular person or the general public.
6.
Notification and Communication With Family. We may disclose your Medical Information to notify or assist in notifying a family member,
your personal representative or another person responsible for your care about your location, your general condition or, unless you had
instructed us otherwise, in the event of your death. In the event of a disaster, we may disclose Medical Information to a relief organization
so that they may coordinate these notification efforts. We may also disclose Medical Information to someone who is involved with your
“Medical Information” shall mean “protected health information” as defined under 45 C.F.R. §160.103.
“Applicable Law” is defined as all applicable Georgia statutes, rules, and regulations and any applicable federal statutes, rules, and
regulations, including without limitation, the Medical Information Portability and Accountability Act of 1996, as amended by the
Medical Information Technology for Economic and Clinical Health Act of 2009, and any of their implementing regulations.
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Helping Children Grow
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Sunshine Pediatric Therapy, LLC
5 Ivy Lawn Place . Greenville, SC 29605
770-256-9921 (Phone) . 404-596-5433 (Fax)
www.sptherapy.com
care or helps pay for your care. If you are able and available to agree or object, we will give you the opportunity to object prior to making
these disclosures, although we may disclose this information in a disaster even over your objection if we believe it is necessary to respond
to the emergency circumstances. If you are unable or unavailable to agree or object, our health professionals will use their best judgment
in communication with your family and others.
7.
Judicial and Administrative Proceedings & Law Enforcement. We may, and are sometimes required by Applicable Law, to disclose your
Medical Information in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or
administrative order or to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or
missing person, complying with a court order, warrant, grand jury subpoena and other law enforcement purposes.
8.
Other Permitted and Required Disclosures Under Applicable Law. We may, and are often required by Applicable Law, to disclose your
Medical Information:

To coroners, medical examiners, and funeral directors in connection with their investigations of deaths or other duties as
authorized by Applicable Law;

To organizations procuring, banking, or transplanting organs and tissues;

To a school that is required to have immunization records before admitting a student where you have agreed to the disclosure
on behalf of yourself or your dependent;

For specialized government functions such as for military or national security purposes or to correctional institutions or law
enforcement officers that have you in their lawful custody; and

As necessary to comply with workers’ compensation laws.
9.
Breach Notification. In the case of a breach of unsecured Medical Information, we will notify you as required by Applicable Law. If you
have provided us with a current e-mail address, we may use e-mail to communicate information related to the breach. We may also
provide notification by other methods as appropriate.
B.
When We May Not Use or Disclose Your Medical Information
Except as described in this Notice of Privacy Practices, Sunshine Pediatric will, consistent with its legal obligations under Applicable Law, not
use or disclose Medical Information which identifies you without your written authorization such as for the use and disclosure:
1.
Of Sensitive Medical Information;3
2.
For marketing purposes;
3.
Constituting the sale of Medical Information;
4.
Other uses not described in this Notice.
If you do authorize Sunshine Pediatric to use or disclose your Medical Information for another purpose, you may revoke your authorization in
writing at any time.
C.
Your Medical Information Rights
1.
Right to Request Special Privacy Protections. You have the right to request restrictions on certain uses and disclosures of your Medical
Information by executing our Request for Restrictions on Use and Disclosure of Protected Health Information form, which will be provided
to you upon request. This written request will specify what Medical Information you want to limit, and what limitations on our use or
disclosure of that information you wish to have imposed. If you tell us not to disclose Medical Information to your commercial health plan
concerning health care items or services for which you paid for in full out-of-pocket, we will abide by your request, unless we must
“Sensitive Health Information” includes any: (i) drug and alcohol records as defined by 42 C.F.R. Part 2; (ii) genetic information as
defined by O.C.G.A. §§ 33-54-3 and 33-54-6; (iii) mental health records as defined by 45 C.F.R. §164.508(a)(2) and O.C.G.A. §§ 249-21 and 43-39-16; (iv) HIV/AIDS information as defined by O.C.G.A. § 24-9-47; and (v) mental retardation records as defined by
O.C.G.A. § 37-4-125.
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Helping Children Grow
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Sunshine Pediatric Therapy, LLC
5 Ivy Lawn Place . Greenville, SC 29605
770-256-9921 (Phone) . 404-596-5433 (Fax)
www.sptherapy.com
disclose the information for treatment or legal reasons. We reserve the right to accept or reject any other request, and will notify you of our
decision.
2.
Right to Request Confidential Communications. You have the right to request that you receive your Medical Information in a specific way
or at a specific location. For example, you may ask that we send information to a particular e-mail account or to your work address. We
will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications.
3.
Right to Inspect and Copy. You have the right to inspect and copy your Medical Information, with limited exceptions. To access your
Medical Information, you must submit a written request detailing what information you want access to, whether you want to inspect it or
get a copy of it, and if you want a copy, your preferred form and format. We will provide copies in your requested form and format if it is
readily producible, or we will provide you with an alternative format you find acceptable, or if we can’t agree and we maintain the record in
an electronic format, your choice of a readable electronic or hardcopy format. We will also send a copy to any other person you designate
in writing. We will charge a reasonable fee which covers our costs for labor, supplies, postage, and if requested and agreed to in advance,
the cost of preparing an explanation or summary. We may deny your request under limited circumstances. If we deny your request to
access your child's records or the records of an incapacitated adult you are representing because we believe allowing access would be
reasonably likely to cause substantial harm to the patient, you will have a right to appeal our decision.
4.
Right to Amend or Supplement. You have a right to request that we amend your Medical Information that you believe is incorrect or
incomplete. You must make a request to amend in writing, and include the reasons you believe the Medical Information is inaccurate or
incomplete. We are not required to change your Medical Information, and will provide you with information about Sunshine Pediatric’s
denial and how you can disagree with the denial.
5.
Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of your Medical Information made by
Sunshine Pediatric, except that Sunshine Pediatric does not have to account for the disclosures provided to you or pursuant to your
written authorization, disclosures to persons involved in your care, disclosures described in paragraphs 1 (treatment), 2 (payment), 3
(health care operations), and 8 (specialized government functions) of Section A of this Notice of Privacy Practices, disclosures for
purposes of public health which exclude direct patient identifiers, or which are incident to a use or disclosure otherwise permitted or
authorized by Applicable Law, or disclosures to a health oversight agency or law enforcement official to the extent Sunshine Pediatric has
received notice from that agency or official that providing this accounting would be reasonably likely to impede their activities.
6.
Right to a Paper or Electronic Copy of this Notice. You have a right to notice of our legal duties and privacy practices with respect to your
Medical Information, including a right to a paper copy of this Notice of Privacy Practices, even if you have previously requested its receipt
by e-mail.
If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact the
Contact Person listed at the top of this Notice of Privacy Practices.
D.
Changes to this Notice of Privacy Practices
We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by
Applicable Law to comply with the terms of this Notice currently in effect. After an amendment is made, the revised Notice of Privacy Practices
will apply to all protected Medical Information that we maintain, regardless of when it was created or received. We will provide you a copy upon
request, post a current notice in our office, and will also post it on our website.
E.
Complaints
Complaints about this Notice of Privacy Practices or how Sunshine Pediatric handles your Medical Information should be directed to Karen
McCullough listed at the top of this Notice of Privacy Practices.
If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:
Roosevelt Freeman, Regional Manager
Office for Civil Rights
U.S. Department of Health and Human Services
Sam Nunn Atlanta Federal Center, Suite 16T70
Helping Children Grow
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Sunshine Pediatric Therapy, LLC
5 Ivy Lawn Place . Greenville, SC 29605
770-256-9921 (Phone) . 404-596-5433 (Fax)
www.sptherapy.com
61 Forsyth Street, S.W.
Atlanta, GA 30303-8909
Voice Phone (800) 368-1019
FAX (404) 562-7881
TDD (800) 537-7697
OCRMail@hhs.gov
The complaint form may be found at www.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaint.pdf.
You will not be penalized in any way for filing a complaint.
Acknowledgement of Receipt of Privacy Practices:
I, ___________________________, have received a copy of the Notice of Privacy Practices from Sunshine Pediatric
Therapy, LLC and understand that the effective date of this document is September 23, 2013.
Name of Patient: ____________________________________________________________
Signature of Patient/Responsible Party _________________________________________
Date: _________________________
Helping Children Grow
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