Beyond Limits Pediatric Therapy Center, LLC

Current Patient

Updated Admissions Form

Child’s Name:*

First Name:*

Last Name:*

Goes by:

DOB:*

Gender *

Male Female

Diagnosis:

Concerns that you would like addressed in therapy:

Address:*

City:*

State:*

Zip:*

First and Last Name of Parent(s)/Guardian:*

I consent to be contacted by the phone numbers and emails below:

Parent/Guardian 1

Home Phone:

Cell Phone:

Work Phone:

Email: *

Parent/Guardian 2

Home Phone:

Cell Phone:

Work Phone:

Email:

If anyone other than the parent(s)/guardian(s) listed above brings my child to therapy (such as grandparent(s), babysitter(s), family friend(s), etc.), I authorize the therapist(s) working with my child to discuss that therapy session with that person/persons.

Date *:

Parent/Guardian Signature *

Person to Contact in Case of Emergency

First and Last Name:*

Relationship:*

Cell Phone:*

Home Phone:

Work Phone:

Transport to Which Hospital in Case of Emergency:

Primary Care Physician:*

Phone:

!! Attention Parents !!

If you have ANY insurance policy IN ADDITION TO A MEDICAID POLICY, you MUST disclose that information. Failing to notify us is considered FEDERAL INSURANCE FRAUD and could result in loss of Medicaid Benefits!! You will be fully responsible for all unpaid claims as a result of any undisclosed policy.

Primary Insurance:*

Policy Number:*

Insurance Phone:

Employer:

Policy Holder:*

Relationship to Patient:

Policy Holder Date of Birth:*

Policy Holder Soc Sec #:

If possible, please upload a copy of your insurance card. Otherwise, please bring with you to your first appointment.

Secondary Insurance:

Policy Number:

Insurance Phone:

Employer:

Policy Holder:

Relationship to Patient:

Policy Holder Date of Birth:

Policy Holder Soc Sec #:

If possible, please upload a copy of your insurance card. Otherwise, please bring with you to your first appointment.

Additional BLPTC Policies

By initialing below, you acknowledge that it is your responsibility to notify BLPTC of any changes at any time in insurance or Medicaid coverage prior to receiving treatment. If you fail to notify BLPTC of any change in coverage and services are denied or non-covered, you will be responsible for the full amount of charges for services rendered at our self-pay rate. It is federal fraud to fail to notify us of any other insurance coverage you may have in addition to any form of Medicaid.

Parent/Guardian Initial*

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If the services your child receives from BLPTC are covered by a third-party payor, BLPTC agrees to file a claim and accept payment from such third party. If the third-party payor determines that a portion of the claim(s) are your responsibility, you will be required to make payment upon receipt of services or at the receipt of notification of such responsibility, as is appropriate. In the case of services which you agree to receive, but which are not covered by the third party, payment will be due upon receipt of services.

Parent/Guardian Initial*

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In the case of a provider’s absence, if an opening is available for a patient to be treated at the same time with an alternate provider, the appointment will be moved to another provider’s scheduler to ensure care may be provided. If an appointment cannot be directly moved, BLPTC staff will utilize the above-listed contact information in order to notify and attempt to reschedule when possible.

Parent/Guardian Initial*

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It is the policy of BLPTC that parents/guardians remain on the premises throughout the full duration of all treatments in case of emergency. Failure to comply with this policy in any capacity may result in a discontinuation of services and/or contacting proper authorities. BLPTC is not responsible for any individual prior to the beginning or after the end of treatment, including sessions that are started late or ended prematurely for any reason at the discretion of the patient’s rendering provider.

Parent/Guardian Initial*

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BLPTC requires a 24-hour notice for cancellations. In the event of a cancellation, please make an effort to reschedule missed appointment(s). After 2 no-shows or cancellations with less than 24-hour notice, BLPTC reserves the right to remove any patient from the schedule, and he/she will be seen on a call-in basis. It will be the responsibility of the parent/guardian to contact our office for availability of call-in sessions.

Parent/Guardian Initial*

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By signing below, I authorize BLPTC to bill my insurance company for direct reimbursement of therapy services rendered to my child and authorize release of any medical information necessary to process the claim. I assign benefits for filed claims to be paid to BLPTC and will turn over any payments sent directly to me by my insurance provider that were intended to cover services provided by BLPTC. I understand that I am responsible for payment of any services not paid or not paid in full by insurance, including those not paid or non-covered as result of my failure to disclose policy coverage or change in policy coverage.

By signing this document, I certify that I have read and understand its contents and that information provided by me is accurate and complete (including insurance information and current eligibility for benefits).

Parent/Guardian Initial*

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ATTENDANCE POLICY

Purpose

At Beyond Limits Pediatric Therapy Center, we believe that consistent attendance is critical to every child's success in therapy. Along with home exercises and activities recommended by your child's therapist(s), regular attendance is essential for achieving the goals set forth in your child’s individualized plan of care.

Importance of Attendance

Ongoing insurance approvals are contingent upon the patient's attendance and the parent/guardian's demonstrated commitment to home exercises. To support our mission of ensuring each child reaches their goals in the anticipated time frame, we have established the following attendance policy.

Attendance Policy for Ongoing Scheduling

Cancellations: Each patient is allowed two cancellations per patient (NOT PER SERVICE/THERAPY/DAY OF THERAPY) in a pre-established two-month period without penalty. Makeups for missed appointments are strongly encouraged.
No-Shows: An appointment is considered a no-show with less than 30-minutes notice, no notice, or a tardy exceeding 15 minutes. Upon the second no-show, the patient transitions to flex scheduling.
Transition to Flex Scheduling (Cancellations): On the third cancellation, the patient will be moved to flex scheduling unless at least one previous cancellation has been made up before this third occurrence. If one previous cancellation was made up, families may choose flex scheduling or adjust their ongoing appointment time.
Notification for Makeups: Parents/guardians must inform the front desk upon arrival that they are checking in for a make-up session to receive credit.
Multiple Appointments: With multiple services per week, any three cancellations combined (across all therapies) leads to flex scheduling for all therapies.
Occurrences Per Absence: If multiple therapies occur on the same day and are missed, it counts as one cancellation total, not multiple.

Attendance Policy for Flex Scheduling

Consecutive Attendance for Return to Ongoing Scheduling: Attending four consecutive appointments on flex scheduling allows families to request returning to ongoing scheduling (subject to availability).
Day-to-Day Flex: A no-show on week-by-week flex scheduling results in day-to-day scheduling, where appointments can only be scheduled on the same day.
Return to Week-to-Week Flex: Attending four consecutive day-to-day flex appointments allows a return to week-to-week flex scheduling.
Discontinuation of Treatment: Missing a day-to-day flex appointment may result in discontinuation of treatment.

Conclusion

We appreciate your understanding and commitment to your child's therapy journey. By adhering to this attendance policy, we help ensure that all patients receive the consistent care necessary to achieve their goals. Thank you for partnering with us in your child’s success!

Parent/Guardian Acknowledgement

By signing below, Parent/Guardiam Acknowledges the Attendance Policy and agrees to adhere to the policy

Patient Name:

Parent/Guardian Name:

Signature:

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Date:

Receipt of Records Consent

By consenting below, I authorize the office staff at Beyond Limits to send my child's evaluations, plans of care, progress notes, and all other medical records or information to the email address on file and any email forwarded or transferred to that email. This will allow me to stay informed about the goals and objectives being addressed in therapy and support these efforts at home. Beyond Limits uses a HIPAA-compliant email system to ensure the security of your child's medical records.

I acknowledge that I must opt in to receive these records via email.

Please choose one option:

I Accept (Opt In)

I Decline (Opt Out)

Please initial below to confirm your acceptance or declining of this service.

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