Metro Therapy Special Children's Clinic, Inc.

PATIENT INFORMATION - This information is confidential

Please correct the errors described below.

Patient Information

Child's Primary Care Physician

Insurance Information

  • I AGREE TO PAY Metro Therapy Special Children's Clinic for the services provided.
  • I am responsible for all charges regardless of insurance coverage and whether or not paid by my insurance company.
  • I understand that I am responsible for contacting my insurance company to verify therapy benefits.
  • I am also responsible to confirm the required referral or authorization with my insurance company prior to receiving therapy services.
  • I am responsible for any denied charges. I am liable for all charges my insurance denies that are the result of changes to my insurance policy or company charges.
  • I consent for this provider to render treatment.
  • I give authorization to be treated within the therapy clinic in areas not totally isolated from other patients and personnel.
  • This authorization or photocopy will authorize the release of any medical information necessary to treat you and/or to process claims for services rendered by this provider to the patient's physician or 3rd party payer that is stated on this form.
  • I request and authorize my insurance company and/or M.A. to make payments to authorized benefits on my behalf to this provider.
  • I understand the information provided above and I have provided accurate information to the best of my knowledge.
  • I have received a copy of Metro Therapy Special Children's Clinics, Inc. Notice of Privacy Practices.

General Information

School Information

If yes, please bring a copy of the IEP/IFSP to your child's evaluation.

Medical Information and Secondary Physicians (if any)

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Has your child previously received evaluations or treatment by other specialists (psychologist, allergist, gastroenterologist, neurologist, etc.)?

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Has your child had any of the following? If yes, please describe and provide approximate dates.

Please list any medications your child is CURRENTLY taking, its purpose and frequency of the dosage.

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Pregnancy and Child's Birth

Motor Development

Please provide the age at which your child:

Please provide how well your child can do the following:

Speech-Language Development

Functional Goals

What are some of the functional outcome goals you would like to have for your child as a result of direct SPEECH-LANGUAGE THERAPY? (goals should be related to home/school/community in the areas of communication, play, social interaction, etc.)

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What are some of the functional outcome goals you would like to have for your child as a result of direct OCCUPATIONAL THERAPY? (goals should be related to home/school/community in the areas of play, daily living skills, school, work, etc.)

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What are some of the functional outcome goals you would like to have for your child as a result of direct PHYSICAL THERAPY? (goals should be related to home/school/community in the areas of play, daily living skills, school, work, etc.)

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Feeding History

At what age did your child transition from:

Please select any aversions/problems or preferences your child may have. Included are examples of each food group.

Food Checklist

Check all liquids that apply:

Fast Foods / Restaurants

Metro Therapy Special Children's Clinic, Inc. Authorizations

Patient Release and Authorization

I, (Parent), authorize the use and/or disclosure of health information as set forth below for (child).

1. The following health information may be used and/or disclosed pursuant to this authorization:

2. I authorize Metro Therapy to receive/give health information regarding this child.

3. I authorize the following person(s) or class of person(s) to receive/give health information concerning this child:

4. I understand I have the right to revoke this authorization at any time, except to the extent that the person(s) or class of person(s) to whom I have authorized such use and/or disclosure have acted in reliance upon this authorization. In order to revoke this authorization, I must provide Metro Therapy S.C.C., Inc. in writing specifically revoking this authorization.

5. I understand that my health information may no longer be protected by the federal privacy protection regulations, 45 C.F.R. parts 160 and 164, if my health information is used or disclosed pursuant to this authorization.

6. I acknowledge that I have been provided with a Notice of Privacy Policy either electronically or in person and agree to the terms therein.

Authorized Pick Up

We understand that children may be picked up by adults, other than their parent and/or guardian. In order to protect your child, we are asking that you let us know, in advance, if you will have someone picking your child up from Metro Therapy. You may pre-authorize adults by completing the information below. Please let the authorized person know that photo identification may be required if a staff member is unfamiliar with them.

Add another person

I authorize the above person(s) to pick up my child from Metro Therapy. I understand this permission will be in place until I communicate a change, in writing, to Metro, and Metro will not release my child to anyone that is not listed without my written ( or verbal) consent.

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