Patient Registration | Children's Therapy of Woodinville

This form will take 15-20 minutes for you to fill out (depending on the complexity of your child’s needs). It includes Registration information as well as pertinent medical and developmental history. It is important for us to have current information to provide the best quality therapy for your child. We appreciate your diligence in filling these forms out accurately.

If you run out of time and need to come back to the form, use the "Save and Continue" link at the bottom of each page to get an email with a special link that will let you pick up and continue later.
Patient Name
First Last
Date of Birth
Age
Grade
School
Gender
- Male
- Female
Address
Street Address City State ZIP Code
Home Phone
Cell Phone
Email
Emergency Contact Phone*
Emergency Contact Name and Relationship to Child*
Caregiver Name #1*
First Last
Caregiver Name #2
First Last
Best Contact Method
Check all that apply.
- Home
- Cell
- Email
Insurance Information
Primary Insurance Company*
Primary Subscriber Name*
First Last
Subscriber Employer*
Subscriber ID Number, including Alpha Prefix*
Plan/Group Number*
Primary Subscriber Birthdate*
Relationship to Patient*
Home Phone
Work/Cell
Secondary Insurance Company or Funding Source
Subscriber Name
First Last
Subscriber ID Number
Plan/Group Number
Subscriber Birthdate
Primary Doctor Information
Primary Care Doctor Name
First Last
Phone
Address
Street Address City State ZIP Code
Primary Referral Concern/Diagnosis
I authorize treatment of the person named above and agree to pay all fees for such treatment. I authorize Children's Therapy of Woodinville, PLLC or the therapist to release any information to process medical claims. I also authorize my insurance benefits to be paid directly to the clinic. I further understand that I am responsible for charges associated with medical services and agree to pay those charges which are my responsibility. I understand that a $45 fee (RCW62A.3-515&520) for returned checks will be charged. *Any unpaid balance over 60 days is subject to a 1.5% late fee added monthly. An unpaid patient balance over 120 days may be sent to collection.
Signature (Parent or Guardian)
Use your mouse or finger to sign.
Hidden
Digital Signature
An actual signature may be required upon visiting the office.
- Please check this box, acknowledging the above. This acts as a digital signature.
Date of Signature
MM slash DD slash YYYY

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Important Financial Information
It is important that you be familiar with your insurance coverage for a specific therapy. In order to provide uninterrupted therapy treatment, it is necessary to be aware of what insurance requirements apply to your plan.

As a courtesy to you, our office will contact your insurance company to see what therapy benefits apply to your plan. We are not responsible for the information we receive from the insurance company. Benefits are often misquoted over the phone. Final determination of benefits is established when a claim is submitted and either paid or denied. We strongly encourage you to call your insurance company and get information about your plan benefits for therapy. The contract with the insurance company is between you and that company, our office is not involved.
- Please notify our office 24 hours in advance if you must cancel. Patients on our waiting list can be seen when we have these openings.
- “No shows” and late cancellations (same day as therapy) adversely affect therapy and are costly to this office. We do charge a $50 Late Cancellation fee and a $75 No Show fee which will be charged directly to the patient. Two “no shows” may result in the loss of your therapy time slot.
- Late arrival to session: Consistent, on time attendance to therapy maximizes progress and allows our clinician to address all goals for your child. We are unable to bill your insurance for the time that is missed due to a late arrival. The following fees will be charged for consistent late arrivals to therapy: OT/PT/Nutrition Services:8-15 minutes: $35.00; 16-30 minutes $60.00; >30 minutes; considered a no show, $75.00, clinician will not have adequate time to address treatment goals. Speech Therapy: 8-20 minutes $35.00; More than 20 minutes will be considered a no show $75.00, clinician will not have adequate time to address treatment goals
- Late pick-up: $50.00 when a child is picked up past the end of their therapy session. Our clinicians have other responsibilities and cannot wait with your child beyond the end of the session.
- We will bill your primary insurance for insurance companies we contract with (i.e., preferred provider). If we are not a preferred provider for your insurance, our office will supply a detailed statement upon request, however, any evaluations and treatment sessions will be considered private pay and are due at each visit.
- Co-pays are due at each visit.
- When we receive payment from your insurance, we will bill you for any outstanding balance. Payment is due upon receipt of your bill and can be paid via My Provider Link, at childrenstherapyofwoodinville.com or in office.
- Pre-authorization: If the need for per-authorization is stated upon our initial insurance check, our office will automatically submit necessary paperwork. However, we strongly recommend that you confirm with your insurance if pre-authorization is needed, as this is often not stated during online benefits check. It is your responsibility to notify our office if your insurance requires pre-authorization for services. Failure to notify us of the need for pre-authorization can result in claims being denied, as most insurers do not allow retroactive pre-authorization. Any claims that are unpaid due to this reason will be the patient’s responsibility.
- Any unpaid patient balance over 60 days will be charged 1.5% late fee for each month outstanding, which will be added to your account balance
- Patient balances unpaid after 120 days will be considered for collection services and could result in your child losing their ongoing therapy time.
- If you change your insurance plan or company, please let us know as soon as possible to expedite correct billing. The final responsibility for your insurance coverage and your therapy bill lies with you.
- Re-Submitting Claims Fee: Resubmitting claims to insurance is costly to our clinic and can impact our fee schedule with our contracted insurers. Therefore, any claims that must be resubmitted due to failure to notify us of insurance changes, secondary insurance, or any medical diagnoses will be charged a $2.00 resubmission fee, which will be patient responsibility. It is the caregiver’s responsibility to notify us as soon as possible of updated insurance information.
- Other Special Provisions
- Name
  First Last
- Date
  MM slash DD slash YYYY
- Signature of Parent/Guardian
  Use your mouse or finger to sign.
- Hidden
  Digital Signature
  An actual signature may be required upon visiting the office.
  - Please check this box, acknowledging the above. This acts as a digital signature.
- Date of Signature
  MM slash DD slash YYYY

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Physician
Physician Name
First Last
Clinic Name
Address
Street Address City State ZIP Code
Phone
Fax

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Naturopath
Naturopath Name
First Last
Clinic Name
Address
Street Address City State ZIP Code
Phone
Fax

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Occupational Therapist
Occupational Therapist Name
First Last
Clinic Name
Address
Street Address City State ZIP Code
Phone
Fax

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Physical Therapist
Physical Therapist Name
First Last
Clinic Name
Address
Street Address City State ZIP Code
Phone
Fax

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Speech Therapist
Speech Therapist Name
First Last
Clinic Name
Address
Street Address City State ZIP Code
Phone
Fax

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Audiologist
Audiologist Name
First Last
Clinic Name
Address
Street Address City State ZIP Code
Phone
Fax

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Chiropractor
Chiropractor Name
First Last
Clinic Name
Address
Street Address City State ZIP Code
Phone
Fax

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Developmental Optometrist
Developmental Optometrist Name
First Last
Clinic Name
Address
Street Address City State ZIP Code
Phone
Fax

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Educational Provider
Educational Provider Name
First Last
Clinic Name
Address
Street Address City State ZIP Code
Phone
Fax

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Neurologist
Neurologist Name
First Last
Clinic Name
Address
Street Address City State ZIP Code
Phone
Fax

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Psychologist
Psychologist Name
First Last
Clinic Name
Address
Street Address City State ZIP Code
Phone
Fax

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Other
Other Provider Name
First Last
Clinic Name
Address
Street Address City State ZIP Code
Phone
Fax

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Authorization for Emergency Care
Should a parent or guardian be away from the clinic at any time during the therapy session, this form authorizes the staff at Children’s Therapy of Woodinville to act in case of emergency.
Patient Name*
First Last
Date of Birth*
Parent/Guardian Name*
First Last
I hereby authorize the staff at Children's Therapy of Woodinville, PLLC to call for appropriate emergency medical treatment for the patient named above.*
Use your mouse or finger to sign your signature in the box.
Hidden
Digital Signature
An actual signature may be required upon visiting the office.
- I hereby authorize the staff at Children's Therapy of Woodinville, PLLC to call for appropriate emergency medical treatment for the patient named above.
Date of Signature
MM slash DD slash YYYY
Please check the following that apply to your child*
You will be asked to describe them next.
- Has allergies
- Is allergic to medicines
- Is taking medications
- Has pertinent medical history that would affect emergency care
- None of the above apply
Allergies
Medicine child is allergic to
Medications your child is currently on
Pertinent medical history that would affect emergency care

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NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ CAREFULLY.

We respect our legal obligation to keep your health information private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding it. The Privacy Policy contact person is Katie Clutter. She can be reached at 425-486-7710 or email .

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; sending out information to you, i.e. billing statements, appointment reminders, etc.; calling you to remind you of your appointment date and time; notifying you by mail or phone about classes, seminars, etc.; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). “Health care operations” mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION
In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:
- when a state or federal law mandates that certain health information be reported for a specific purpose;
- for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;
- disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
- uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
- disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
- disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;
- disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
- uses or disclosures for health-related research;
- uses and disclosures to prevent a serious threat to health or safety;
- uses and disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
- disclosures of de-identified information;
- disclosures relating to worker’s compensation programs;
- disclosures of a “limited data set” for research, public health, or health care operations;
- incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
- disclosures to “business associates” who perform health care operations for us and who commit to respect the privacy of your health information;
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The law gives you many rights regarding your health information. You can:
- ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the office contact person at the address, fax or email shown at the beginning of this Notice.
- ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using email to your personal email address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office contact person at the address, fax or email shown at the beginning of this Notice.
- ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or sixty days if the information is stored off-site). You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30-day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office contact person at the address, fax or email show at the beginning of this Notice.
- ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, send a written request, including your reasons for the amendment, to the office contact person at the address, fax or email shown at the beginning of this Notice.
- get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list will not include: disclosures of purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 days extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office contact person at the address, fax or email shown at the beginning of this Notice.
- get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written request to the office contact person at the address, fax or email shown at the beginning of this Notice.
OUR NOTICE OF PRIVACY PRACTICES
By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allows by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our Website.

COMPLAINTS
If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office of Civil Rights. We will not regulate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or email shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.

FOR MORE INFORMATION
If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the beginning of this Notice.
I acknowledge that I received a copy of the Notice of Privacy Practices.
Use your mouse or finger to sign.
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Digital Signature
An actual signature may be required upon visiting the office.
- I acknowledge that I received a copy of the Notice of Privacy Practices.
Date of Signature
MM slash DD slash YYYY

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Treatment Contract
We appreciate your business and are committed to the progress of your child toward their therapy goals. To that end, we want to commit to services we will provide you and we need you to commit to our clinic guidelines. Regular weekly attendance is necessary for maximizing the benefits of therapy and leads to achieving goals more quickly.

Therapist’s Commitments:
Your child’s therapist will complete an evaluation and develop a treatment plan with specific goals based on your areas of concerns and your child’s areas of need. You will be provided a written report that will also be sent to other professionals working with your child (with your written consent). The therapist will be happy to answer any questions related to treatment during therapy sessions. Specific recommendations for home activities to support progress in goal areas will be given. The therapist will keep you informed through verbal communication of how your child is doing in therapy. Progress towards goals will be formally assessed and a written report provided on a regular basis. The therapist will inform you when discharge is recommended, which could be due to a lack of progress towards goals or when a child has met the goals of therapy.

Your child’s therapist is committed to seeing your child for each scheduled appointment. If the therapist will be out of the office we will give you as much notice as possible. We will also provide the opportunity to reschedule if possible.
Parent and Child Commitments (Please check each box to signal acknowledgment that you have read and agree).*
- I will arrive and pick up my child on time for our scheduled appointments.
- If my child is ill, I will call as soon as possible to cancel our appointment.
- If I need to cancel (other than for my child’s illness) I will give at least 24 hours’ notice. If I cancel with less than 24 hours’ notice, I will be charged a Late Cancellation fee of $50. If I No Show, I will be charged a $75 No Show fee. Two of these charges may result in the loss of my child’s therapy time.
- I will call 425-486-7710 to cancel an appointment. If I email a cancellation notice, I understand that I must receive a confirming return email in order for the appointment to be considered cancelled.
- I will make every effort to schedule a make-up appointment on an ‘as available’ basis.
- When home recommendations are given, if we have any questions or concerns we will discuss them with our therapist. We will then commit to doing those activities and report back the following session.
- In order to keep the appointment time reserved for my child, I understand we must maintain good attendance. This means calling in advance for missed appointments and attending at least 80% (5/6) of my scheduled on-going appointments. I understand that if my child’s attendance fall below 80% in a six-week period, I may lose my recurring appointment time. Progress cannot be made if my child is not attending therapy sessions.
- I understand if I have a planned absence from therapy for more than two weeks, I have the option to pay $75 per session that I miss (for each therapy) in order to hold my child’s therapy spot. This charge applies to any session after the first two appointments that I miss. I can also choose to discontinue therapy and be placed on the CTW waiting list when I am able to commit to weekly therapy.
I have read the Treatment Contract and agree to the provisions listed above
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Digital Signature
An actual signature may be required upon visiting the office.
- I acknowledge that I received a copy of the Notice of Privacy Practices.

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Indirect Therapy Services
Please be advised that any extra services that are provided outside of your child’s therapy sessions will be billed at an hourly rate of $150. You will be billed directly for any of the following services: Additional report requests; parent meetings; meetings or conference calls or written communication with other professionals (school team, IEP, ABA etc.); training of home caregivers/tutors; and observations/consultations in schools. Phone calls that last longer than 10 minutes may also be billed at the above hourly rates.

Consultation with Parents in person or via phone – (child not present) $150 per hour
(Insurance excluded – this service cannot be submitted to insurance)

School Meeting or Consultation – (child not present) These appointments can be made at the discretion of the therapist (per their schedule; distance of school, etc.) Base fee is $250, which includes 60 minutes for consultation, up to 30 min drive time, and a brief summary of recommendations (if needed). If drive time is longer, additional fees may apply.
(Insurance excluded – this service cannot be submitted to insurance)

School Recommendations or Requested Additional Written Report or Communication: Written Report $150
(Insurance excluded – this service cannot be submitted to insurance)

Email Communication: We will occasionally communicate with parents via email. This is generally for scheduling purposes. It is often difficult for the therapist to respond quickly to email communications. It could take up to 48 hours for a therapist to reply.

If you email questions about your child's treatment, please understand that typically your therapist will not be able to respond about treatment by email. They would be happy to discuss your questions at your child's next appointment where they can make sure that the information and recommendations are clearly understood and also answer any follow up questions.
Signature
Hidden
Digital Signature
An actual signature may be required upon visiting the office.
- Please check this box, acknowledging the above. This acts as a digital signature.

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Developmental History
Medical Diagnosis*
Is your child receiving any other therapy services?*
Is your child participating in any social/community activities?
What are your child's favorite play interests?
What are your primary concerns for your child? ( Academic, behavioral, communication, social, sensory, gross/fine motor)*

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Family Members
Parent 1
First Last
Parent 1 Occupation
Parent 2
First Last
Parent 2 Occupation
Marital Status
- Married
- Separated
- Divorced
Siblings
Name Age Gender

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Age when adopted?
Country adopted from?
Any known pregnancy and delivery information
Any known family health history
Is your child aware of adoption?

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Speech and/or Occupational Therapy
Are you seeking Speech and/or Occupational/Physical Therapy?*
- Yes, Speech
- Yes, Occupational/Physical Therapy
ALERT: You are on the last page of this section. Please be sure you have completed all the previous pages before you move on.

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Hearing History
If your child has had ear infections, how were they treated?
Has your child been treated with tubes?
- Yes
- No
How many sets?
How long did they last?
Was your child treated with antibiotics?
- Yes
- No
How many courses to clear the infection?
Has your child’s hearing been tested? If so where and when? What were the results?

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Occupational/ Physical Therapy History Form
Motor Development: At what age did your child:
Belly crawl
Sit independently
Crawl on hands and knees
Walk
Begin solid foods
First words

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Social/Emotional
Please describe any difficulties your child may have or had in the following areas: Daycare; Preschool; Kindergarten; Elementary School; Interacting with Peers; Participating in groups; Participating in busy environments (e.g. restaurants, grocery store); Handling unexpected change; Recovering when angry or upset
Please list three priorities that you have for your child if they receive Occupational/Physical therapy at our clinic.
Please write any other comments below
Untitled
Untitled
Untitled

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Patient Registration Form

Insurance Information

Primary Doctor Information

Important Financial Information

Authorization for Exchange of Information

Physician

Naturopath

Occupational Therapist

Physical Therapist

Speech Therapist

Audiologist

Chiropractor

Developmental Optometrist

Educational Provider

Neurologist

Psychologist

Other

Authorization for Emergency Care

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ CAREFULLY.

Treatment Contract

Indirect Therapy Services

Developmental History

Family Members

Pregnancy

Labor and Delivery

Infancy

Childhood Health

Speech and/or Occupational Therapy

Hearing History

Speech and Language History

Occupational/ Physical Therapy History Form

How would you describe your child's motor development?

Self-Care Skills

Dressing/Grooming

Social/Emotional

Our Contact Info

Site Map

Name	Age	Gender