General Information Form and Credit Card Authorization

Please correct the errors described below.

Verification of Eligibility

Patient Info

Responsible Party (Insurance only skip if medicaid or mediwaiver)

Referring Provider

Upload Primary and Secondary Insurance Information (pdf)

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    Upload Prescriptions from Physicians and Care Providers (ST, PT, OT, ABA)

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      By signing this form, you are agreeing to let us use your child’s Protected Health Information (PHI) for the purposes of payment, treatment, and health care operations.

      Photo and Video Consent

      ACKNOWLEDGEMENTS:

      1. I waive all rights that I, on behalf of myself or my child, may have to any claims for payment, royalties or other remuneration in connection with any use, publication or exhibition of the recordings or images.

      2. I understand that the recordings or images will be the sole property of Metamorphosis Therapy, LLC's and will not become part of my medical record or student record

      3. I understand that this material and/or informatino may be shared with the general public. I agree that Metamorphosis Therapy, LLC is not responsible for any misappropriation of the photographs/video, if applicable, by any member of the general public or news.

      4. I understand that I may refuse to sign the Conset and Authorization and that my signature is strictly voluntary and will not impact the services that I or my child receives at Metamorphosis Therapy, ::C.

      5. I understand that I may change my mind and revoke (take back) this Authorization in writing at any time and for any reason.

      6. I understand any images disclosed or used prior to my revocation will not be affected, cannot be taken back and are not subject to revocation. The option to stop production or use does not apply to the news media, as they are not under Metamorphosis Therapy, LLC's control.

      7. A copy of this consent and authorization form will be given to me.

      8. I understand that if I have any questions or concerns I may discuss them with the employees of Metamorphosis Therapy, LLC's presenting me with this form or I may call the Office at 407-397-9976.

      Credit Card Authorization

      I authorize METAMORPHOSIS THERAPY, LLC to charge my credit card provided herein. I agree that I will pay for this purchase in accordance with the issuing bank cardholder agreement.

      Card Holder enter name, electronic sign and date below

      Financial Responsibility

      For participating insurance plans- I authorize the release of any information necessary to process
      medical claims for the patient named above and authorize that payment of benefits for these claims
      be made to Metamorphosis Therapy, LLC. Also, I agree to promptly pay for any services not covered
      by my insurance and or determined to be my responsibility (i.e., Deductibles, Co-payments such as
      20% of the allowable fee for Medical Services when deemed “Reasonable and Necessary”). Insurance
      covers the cost of 30 minute sessions for both Occupational and Speech Therapy. If you would like
      additional therapy for your child we will be billing you for the following additional therapy in 15
      minute increments and the rates are as follows:
      45 minutes session (additional 15 minutes)…………………… $25
      60 minute sessions (additional 30 minutes)……………………$50

      Private Pay – Not using insurance; I am paying by cash, check or credit card at the time of service.
      You have been offered the opportunity to personally pay for treatment at Metamorphosis Therapy,
      LLC.
      The private pay policy is used in the following circumstances:
      1. Patient has no insurance.
      2. Therapy is not covered by patient’s insurance.
      3. Patient chooses to forgo insurance benefits.

      The following conditions apply:
      1. Once you have chosen the private pay terms, we will not bill your insurance carrier for services
      rendered.
      2. We accept cash, debit, credit, or checks. There is a $25.00 service charge for returned checks.

      Payment is due at the time services are rendered. I agree to these payment terms and
      guarantee payment to Metamorphosis Therapy, for any services provided to the patient named
      above.

      Consent for Treatment and Telehealth Services

      Notice of Protected Health Information Privacy Practices Generalized Consent for Treatment

      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

      When we refer to “you” or “your” below, it represents your child or the patient receiving services from Metamorphosis Therapy, LLC.
      As part of the healthcare service you receive from Metamorphosis Therapy, LLC health records are generated and maintained describing your child’s care including, but not limited to, your name,
      address, phone number, social security number, health history,
      symptoms, examination and test results, diagnoses, procedures, treatments, and plans for future care or treatment. This information is called “Protected Health Information” (PHI).

      This Notice of Privacy Practices describes how from Metamorphosis Therapy, LLC may use and disclose your information and the rights that you have regarding your health information.

      Uses and Disclosures of Health Information Without Authorization

      When you obtain services from Metamorphosis Therapy, LLC, certain uses and disclosures of your health information are necessary and permitted by law in order to treat you, to process
      payments for your treatment, and to support the operations of the entity and other involved providers. The following categories describe ways that we use or disclose your information, and some representative examples are provided in each category. All of the
      ways your health information is used or disclosed should fall within
      one of these categories.

      • Your health information will be used for treatment: For example:
      Disclosure of medical information about you may be made to therapists, doctors, nurses, technicians, or others who are involved in treating you. This information may be disclosed to other physicians who are treating you or to other healthcare facilities involved in your care. Information may be shared with pharmacies, laboratories, or radiology centers for the coordination of different treatments.

      • Your health information will be used for payment: For example: Health information about you may be disclosed so that services provided to you may be billed to an insurance company or a third
      party for reimbursement of services rendered. Information may be provided to your health plan about treatment you are going to receive in order to obtain prior approval or to determine if your health plan will cover the treatment.

      • Your health information will be used for health care operations: For
      example: This information in your health record may be used to evaluate and improve the quality of the care and services we provide.

      Disclosures Required by Law or Otherwise Allowed Without Authorization or Notification

      The following disclosures of health information may be made according to state and federal law without your written authorization or verbal agreement. When a disclosure is required by federal, state, or local law, judicial or administrative proceedings, or for law
      enforcement; examples would be reporting gunshot wound or child abuse, or responding to court orders

      •For public health purposes, such as reporting information about births, deaths, and various diseases, or disclosures to the FDA regarding adverse events related to food, medications, or devices

      •For health oversight activities, such as audits, inspections, or licensure investigations

      •To organ procurement organizations for the purpose of tissue donation and transplant

      •To avoid a serious threat to the health or safety of a person or the public

      •Contacting you to provide appointment reminders or to recommend treatment alternatives

      •Notifying you of health-related benefits and services that may be of interest to you

      Required Uses and Disclosures: Under the law, we must make disclosures when required bythe Secretary of the Department of Health and Human Services to investigate or determine
      our compliance with federal privacy law.

      Uses and Disclosures Requiring Authorization

      Any other uses or disclosures of your health information not addressed in this Notice or otherwise required by law will be made only with your written authorization. You may revoke such authorization at any time.

      YOUR INDIVIDUAL RIGHTS UNDER HIPAA

      • You have the right to request restrictions on certain uses and disclosures of your Protected Health Information. For example, you may wish to restrict your employer from knowing about a medical condition. Regardless of your request, please know that the HIPAA rules allow our office to share your Protected Health Information
      with the Covered Entities. If you wish to restrict your PHI please make this request in writing to us and discuss with your therapist.

      • You have the right to receive your Protected Health Information in a confidential communication from our office, such as the US mail. If you have a specific request for communication please discuss this with your therapist or Bridgett Dimant, M.S. CCC-SLP, Owner. You have the right to inspect and copy your Protected Health Information. Copies of your Protected Health Information are available for a reasonable fee paid to our office to cover our expenses of reproducing them. You may request this information at any time via your therapist, the office manager, or Bridgett Dimant, M.S. CCC-SLP, Owner.

      • You have the right to request that we amend your Protected Health Information. In some cases, we may require that these requests be in writing and be supported by a reason for the change. Generally, this will not apply to such routine changes as address or phone number listings.

      • You have the right to receive, upon request, an accounting of your Protected Health Information that we have provided to Non-Covered entities.

      • If you have read and responded to this notice through electronic media such as our website or email, you have the right to receive a paper copy of this notice upon request.

      If you would like to exercises any of these rights, please contact Bridgett Dimant, M.S. CCC-SLP, at (407) 395-9976 and we will make any necessary arrangements for you.

      Metamorphosis Therapy, LLC is required by law to maintain the privacy of your Protected Health Information and to provide you with this notice of our legal duties and privacy practices as they apply to your Protected Health Information. We are also required to abide
      by the terms of this notice, which is currently in effect as of December 15, 2008.

      In the future, we reserve the right to change the terms contained in this notice and make any new provisions effective for all of the Protected Health Information we maintain. In the event we elect to change the terms of this notice, a new notice will be posted in our office. In addition, you may receive notification by direct mail, email, or other such communication as our practice may implement from time to time.

      Should you ever believe your privacy rights have been violated, we request you to file a complaint with our office by contacting us at (407) 395-9976 or by mail to: 1350 West Colonial Drive suite 350-121, Winter Garden, FL 34787. You may also register your complaint with the Secretary of the US Department of Health and Human Services, Office of Civil Rights. As part of our commitment to you, we value your privacy and take every precaution in our practice to preserve your right to that privacy. Any complaint you file will be used strictly to improve our operating procedures and in no way will you be retaliated against for filing a complaint.

      Should you have any questions or concerns, please contact us directly at (407) 395-9976 to obtain further information.

      Generalized Consent for Treatment and Telehealth Services

      I have read and understand the Notice of Protected Health Information Privacy Practices for Metamorphosis Therapy, LLC. I understand that if I do not sign this consent form my child cannot be evaluated or treated by Metamorphosis Therapy, LLC.

      When Metamorphosis Therapy, LLC examines, diagnoses, treats, or refers your child, we will be collecting what the law calls Protected Health Information (PHI) about your child.

      We need to use this information to decide on what treatment is best for your child, provide treatment to your child, and collect payment. We may also share this information with others who provide treatment to your child or need it to arrange payment for your
      child’s treatment or for other business or government functions.

      By signing this form, you are agreeing to let us use your child’s Protected Health Information (PHI) for the purposes of payment, treatment, and health care operations.

      I understand that I have the rights with respect to telehealth:

      1. The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my sessions is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elder, and dependent adult abuse; expressed threats of violence toward an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without my written consent.

      2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.

      3. I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the counselor, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons. CFS utilizes secure, encrypted audio/video transmission software to deliver telehealth.

      4. I understand that if my counselor believes I would be better served by another form of intervention (e.g., face-to-face services), I will be referred to a medical professional associated with any form of rehabilitation, and that despite my efforts and the efforts of my counselor, my condition may not improve, and in some cases may even get worse.

      5. I understand the alternatives to counseling through telehealth as they have been explained to me, and in choosing to participate in telehealth, I am agreeing to participate using video conferencing technology. I also understand that at my request or at the direction of my counselor, I may be directed to “face-toface” rehabilitation.

      6. I understand that I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telehealth in my care, but that no results can be guaranteed or assured.

      7. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my counselor in order to operate the video equipment. The above-mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history that are personally sensitive to me, (2) ask non-clinical personnel to leave the telehealth room, and/or (3) terminate the consultation at any time.

      8. I understand that my express consent is required to forward my personally identifiable information to a third party.

      9. I understand that I have a right to access my medical information and copies of my medical records in accordance with the laws pertaining to the state in which I reside.

      10. By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based rehabilitation services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area.

      11. I understand that different states have different regulations for the use of telehealth. In Wisconsin, telehealth may only be conducted between certified office locations. I understand that, in Wisconsin, I am not able to connect from an alternative location for the provision of audio-/video-/computer based rehabilitation services.

      Payment for Telehealth Services
      Metamorphosis Therapy, LLC_will bill insurance for telehealth services when these services have been determined to be covered by an individual’s insurance plan. In the event that insurance does not cover telehealth, the individual wishes to pay out-of-pocket, or when there is no insurance coverage, a prompt pay discount is available. We will provide you with a statement of service to submit to your insurance company if you wish.

      I have read and understand the information provided above regarding telehealth, have discussed it with my counselor, and all of my questions have been answered to my satisfaction.
      I have read this document carefully and understand the risks and benefits related to the use of telehealth services and have had my questions regarding the procedure explained. I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein.

      By my signature below, I hereby state that I have read, understood, and agree to the terms of this document.

      Sign Below

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