OT/PT Pediatric Intake form

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I have requested medical services from Breslin Occupational Therapy Services on behalf of myself and/or my dependents. I understand that by making this request, I become fully financially liable for any and all charges incurred in the course of the treatment authorized. I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges in full immediately upon presentation of the appropriate statements unless I made other arrangements in advance with Breslin Occupational Therapy Services. I agree to fill out and execute any additional necessary forms that may be required for my insurance carrier. I understand that I am financially responsible to the organization for any charges not covered by health care benefits. It is my responsibility to notify the organization of any changes in my health care coverage. I understand that in some cases, exact insurance benefits cannot be determined until the insurance company receives the claim. I agree that I am responsible for the entire bill of balance of the bill as determined by the organization and/or my health care insurer if the submitted claims or any part of them are denied for payment. I understand that by signing this form, I am accepting financial responsibility as explained above for all payment for products and services received. Assignment of Benefits I hereby assign all occupational therapy benefits to which I am entitled, including major medical benefits, to Breslin Occupational Therapy Services for any medical services they provide to myself and/or my dependents. I hereby authorize and direct my insurance carrier(s), including Medicare, Medi-Cal, private insurance, auto accident insurance, and any other health or medical plan to issue payment/check(s) directly to Breslin Occupational Therapy Services for medical services rendered to myself and/or my dependents, regardless of my insurance benefits, if any. Authorization to Release Information I authorize the release of any medical or other information necessary to determine these benefits or the benefits payable for related equipment or services to the organization, my insurance carrier, or other entity. A copy of this authorization will be sent to my insurance company or other entity, if requested. The original will be kept on file by the organization.

WHAT IS THIS NOTICE? WHY IS IT IMPORTANT? By law, Breslin Occupational Therapy Services must protect the privacy of your identifiable medical and other information (“health information”). We must also give you this notice to tell you how we may use and give out (“disclose”) your health information, and follow the terms of this notice when doing so. This notice is effective as of August 1, 2022. We have the right to change the terms of this notice at any time, including for information received prior to the change. Updated notices will be posted at our office and on our website. You can get a copy of the most recent notice by contacting us. HOW WE MAY USE YOUR HEALTH INFORMATION As a general rule, you must give Breslin Occupational Therapy Services written permission before we can use or release your health information. However, in some situations we do not have to get your permission. This section explains when we can and cannot use or disclose your health information without your permission. Breslin Occupational Therapy Services is allowed to use your information for: • Treatment – We use and disclose your health information to provide you with medical treatment or services. This includes uses and disclosures to: • Treat your illness or injury, including disclosures to other doctors, practitioners, nurses, technicians, or medical personnel involved in your treatment; • Contact you to provide appointment reminders; or • Give you information about treatment options or other health related benefits and services that may interest you. • Payment – We may use and disclose your health information to obtain payment for health care services that we or others provide to you. This includes uses and disclosures to: • Submit health information and receive payment from your health insurer, HMO, or other company that pays the cost of some or all of your health care (“payor”); or • Verify that your payor will pay for your health care. • HOWEVER – We will follow your request to not disclose health information to your health plan if the information relates solely to a healthcare item or service for which we have been paid out of pocket in full. • Health Care Operations – We may use and disclose your health information for our health care operations, such as internal administration and planning that improve the quality and cost effectiveness of the care we provide you. This also includes uses and disclosures to: • Evaluate the quality and competence of our health care providers, nurses, and other health care workers; • Help other health care providers conduct their own quality reviews, compliance activities, or other health care operations; • Train students, residents, and fellows; or • Identify health-related services and products that may be beneficial to your health and then contact you about the services and products. • Business Associates – We may also disclose your health information to third parties who help us with these activities (“Business Associates”) if they agree in writing to maintain the confidentiality of your health information. We may also use and disclose your health information under the following circumstances: • Relatives, Caregivers, and Personal Representatives – Under appropriate circumstances, including emergencies, we may disclose your health information to family members, caregivers, or personal representatives who are with you or appear on your behalf. • If you object to such disclosures, please let us know. If you are not able to tell us your preference (such as if you are unconscious), we may go ahead and share your information if we believe it is in your best interests. • We will only disclose information we believe is directly relevant to that person’s involvement with your health care or payment related to your health care. • Public Health Activities – We may disclose your health information for the following public health activities: • To report to public health authorities for the purpose of preventing or controlling disease, injury, or disability; • To report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; • To report information to the U.S. Food and Drug Administration (FDA) about products and services under its jurisdiction; • To alert a person who may have been exposed to a communicable disease or nay otherwise be at risk of contracting or spreading a disease; or • To report information to your employer as required under laws addressing work- related illnesses and injuries or workplace medical surveillance. • Victims of Abuse, Neglect, or Domestic Violence – If we reasonably believe that you are a victim of abuse, neglect, or domestic violence, we may disclose your health information as required by law to social services or another governmental agency authorized by law to receive such reports. • Health Oversight Activities – We may disclose your health information to a health oversight agency that is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medi-Cal (Medicaid). • Specialized Government Functions – We may use and disclose your health information to units of the government with special functions, such as the U.S. military, under certain circumstances required by law. • Law Enforcement Officials, Judicial and Administrative Proceedings – We may disclose health information to police or other law enforcement officials, or in judicial or administrative proceedings (such as in response to a subpoena). • Coroners or Medical Examiners – We may disclose health information to a coroner or medical examiner as required by law. • Organ and Tissue Donation – We may disclose health information to organizations that assist with organ, eye, or tissue donation, banking, or transplant. • Health or Safety – We may disclose health information to prevent a serious threat to your health and safety or the health and safety of the public or another person. • Limited Data Sets – We may provide identifiable health information about you (but not including your name, address, social security number or other direct identifiers) for research, public health or health care operations, but only if the recipient of such information signs an agreement to protect the information and not use it to identify or contact you. • Marketing Activities – • Without your authorization, we can: provide you with marketing materials in a face- to-face encounter; give you a promotional gift of nominal value; or tell you about our health care products and services. • If we accept payment from other organizations or individuals in exchange for telling you about their health care products or services, we will ask for your authorization, except as described above or unless the communications are allowed by law without your permission. • We will ask your permission to use your health information for any other marketing activities. • From time to time, we receive letters or other testimony from patients, their family members, and friends describing the experience and care they received from us. We may share these letters or testimony with our employees and patients, but prior to doing so we will remove your name and other identifying information to protect your privacy. • Workers’ Compensation – We may disclose health information as authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs or as required under laws relating to workplace injury and illness. • As Required by Law – We may disclose health information when required to do so by any other law not already referred to in the preceding categories. FOR ANY OTHER PURPOSE NOT DESCRIBED ABOVE, WE MAY ONLY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION WHEN YOU GIVE US YOUR WRITTEN AUTHORIZATION. • Highly Confidential Information – Federal and State law require special privacy protections for certain information about you (“Highly Confidential Information”), including your health information that is maintained in psychotherapy notes or is about: • Mental health and developmental disability services; • Alcohol and drug abuse prevention, treatment, and referral; • HIV/AIDS testing, diagnosis or treatment; • Communicable diseases; • Genetic testing; • Child abuse and neglect; • Domestic or elder abuse; or • Sexual assault. In order for your Highly Confidential Information to be disclosed for a purpose other than those permitted by law, your written authorization is required. • Sale of Health Information – We will not make any disclosure that is considered a sale of your protected health information without your written authorization unless the disclosure is for a purpose permitted by law. YOUR RIGHTS & CHOICES You have certain rights when it comes to your health information. • Tell us to share information with certain people – You can tell us to share information with your family, close friends, or others involved in payment for your care. • Ask us to limit what we use or share – You may ask us to: • Not use certain information for treatment, payment, or health care operations. However, we are not required to agree, and may say “no” if it would affect your care. • Not share information for payment or operations with your health insurer regarding health services or items that you fully paid for out-of-pocket. • Not share information in an emergency situation. If you cannot tell us your preference in an emergency situation (such as if you are unconscious), we may go ahead and share your information if we believe it is in your best interests. • Get a copy of your health and claims records – You can make a written request to see or get an electronic or paper copy of your health information. California law requires we give you the chance to view your records within 5 business days or provide copies within 15 business days. Reasonable copy charges may apply.1 We may deny your request if disclosure would reasonably endanger you or another person. Some information may be excluded.2 • Ask us to correct your health and claims information – You can make a written request for us to correct your health and claims records if you think they are incorrect or incomplete. We have 60 days to respond but may have a 30-day extension if we tell you in writing the reason for the delay. We may say “no” to your request, but we will tell you why in writing. If we say no, you can give a statement of up to 250 words to be included in your record. • Request confidential communications – You can ask us to contact you in a specific way, such as on your home phone or office phone, or to send mail to a different address. We will say yes to all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not. • Get a list of who we’ve shared information with – Upon written request, we will give you a list of certain disclosures we have made. Your request can go back up to six years. If you make more than one request during a 12-month period, we will charge you a reasonable fee. • Get a paper copy of this privacy notice. • Choose someone to act for you – If you have given someone medical power of attorney, or someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure that person has authority and can act for you before we take any action. • File a complaint if you feel your rights are violated – If you feel we have violated your rights, you can complain by contacting us, or by filing a complaint with the U.S. Department of Health and Human Services Office for Civil Right by: • Mail: 200 Independence Avenue, S.W., Washington, D.C. 20201 • Phone: 1-877-696-6775 • Online: www.hhs.gov/ocr/privacy/hipaa/complains/ We will not retaliate against you for filing a complaint. 1 Not more than $0.25 per page or $0.50 per page for records copied from microfilm, plus reasonable administrative costs. 2 Such as: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, criminal, civil, or administrative proceedings; or information that is subject to or exempt from Clinical Laboratory Improvement Amendments of 1988. • Right to be notified of breach – We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • Revoke an authorization you previously made – You can take back any written authorization you’ve given for us to use and disclose your health information. However, this won’t affect any uses or disclosures we made previously. Your revocation must be made in writing. FURTHER INFORMATION & COMPLAINTS If you would like additional information about your privacy rights, are concerned that we have violated your privacy rights, or disagree with a decision that we made about access to health information, please contact us. You may also file a written complaint with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Contact us at: • Mail: 20 Hilltop, Redding, California 96003 • Phone: 1-530-780-5559 • Fax: 1-530-338-2125 • Email: info@botsredding.org

At Breslin Occupational Therapy Services, we want to help you reach your physical and occupational therapy goals. To do this, it is extremely important that you attend your appointments. We recommend you arrive at least five minutes early for your appointments. FEE FOR MISSED APPOINTMENTS We charge a $25 fee for missed appointments, including for: • Appointments you miss without giving us at least 24-hours’ notice; and • Appointments to which you are more than 15 minutes late. This fee is not billable to your insurance. You will be fully responsible for any missed appointment fees. 24-HOURS’ NOTICE FOR CANCELLATION Please contact us at least 24-hours in advance if you will not be able to attend your appointment and need to reschedule. Our schedule is very full – giving us advance notice of your cancellation helps us ensure that another patient can get the care they need. If you do not provide at least 24-hours’ notice, you will be charged a $25 for the missed appointment. If you cannot reach us on the phone, please leave us a voicemail to avoid a cancellation fee. RUNNING LATE Please call us immediately if you are running late so that we can talk to your clinician and prepare for your late arrival. If you are late for an appointment, it is taking time away from your care and recovery. We cannot guarantee that we will be able to provide you with your full treatment when you are late, as we have reserved the appointment time following yours for another patient. If you are 15 or more minutes late for your appointment, your appointment will be cancelled and rescheduled, and we will charge you the $25 missed appointment fee. MULTIPLE MISSED APPOINTMENTS If you have multiple same-day cancellations or missed appointments, you may be removed from the schedule. We may also notify your physician, or in the case of worker’s comp cases, claims adjuster, of your non-compliance.

I understand I have the right to informed participation in decisions involving my/my dependent’s health care. Occupational therapy services can have benefits and risks. Informed consent means being aware of both possibilities. Informed consent shall be based on clear, concise explanations of my/my dependent’s condition and all proposed treatment procedures. Benefits of occupational therapy include gaining increased independence, increased motor functioning, increased sensory regulation, and overall greater sense of well-being and health. However, since the physical response to a specific treatment can vary widely from person to person, it is not always possible to accurately predict a person’s response to a certain therapy or procedure. There is always a risk that occupational therapy assessment or treatment may cause pain or injury or may aggravate previously existing conditions. You (or your parent/guardian) have the right to ask questions about what type of treatment will be received and discuss with the clinician the potential risks and benefits of each specific recommendation. You also have the right to decline any portion of treatment at any time during the treatment sessions. I authorize my clinician at Breslin Occupational Therapy Services to examine and treat my/my dependent’s condition as they deem appropriate using occupational therapy measures and for such procedures to be performed. All possible risks and/or side effects as well as the probability of success with such procedures shall be disclosed to me by my attending clinician. I will not hold Breslin Occupational Therapy Services nor my clinician responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I have the right to know who is responsible for authorizing and performing and any and all treatment procedures.

Thank you for your continued support and trust in our practice. As with the transmission of any communicable disease like colds or flus, you may be exposed to COVID-19 (aka Coronavirus) or monkeypox at any time or place. We always follow state and federal regulations, recommended universal personal protection, and disinfection protocols to limit transmission of all diseases in our office. Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to illness in our office. Although we take measures to provide social distancing in our office when possible, because nature of the procedures we provide it is not always possible to maintain social distancing between the patient, therapist, staff, and sometimes other patients.

You are receiving direct physical therapy treatment services from an individual who is a physical therapist licensed by the Physical Therapy Board of California. Under California law, you may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits, whichever occurs first, after which time a physical therapist may continue providing you with physical therapy treatment services only after receiving, from a person holding a physician and surgeon’s certificate issued by the Medical Board of California or by the Osteopathic Medical Board of California, or from a person holding a certificate to practice podiatric medicine from the California Board of Podiatric Medicine and acting within his or her scope of practice, a dated signature on the physical therapist’s plan of care indicating approval of the physical therapist’s plan of care and that an in person patient examination and evaluation was conducted by the physician and surgeon or podiatrist.