Jacksonville Speech & Hearing Center 12.19.14

JACKSONVILLE SPEECH & HEARING CENTER PATIENT INFORMATION FORM

PEDIATRIC (CHILD) - AUDIOLOGY Please Print

Referring Physician:

Child’s (Patient) Name: Gender: Male ¨ Female¨ LAST FIRST MIDDLE

Date of Birth: Age: Ethnicity:

Address: City/Zip: County:

Parent/Guardian: Phone # Alternate Phone #

Address: City/Zip: County:

Email address: ____ Employer: ____________________Work #:_____________________

Parent/Guardian: Phone # Alternate Phone #

Address: City/Zip: County:

Email Address: ______Employer:____________________Work#____________________

Emergency Contact: Relationship: Phone#

INSURANCE INFORMATION:

PRIMARY INS. COMPANY: CARDHOLDER NAME:

POLICY # GROUP # PHONE#

SECONDARY INS. COMPANY: CARDHOLDER NAME:

POLICY # GROUP # PHONE#

**BRING INSURANCE CARD AND PHOTO ID WITH YOU**

Jacksonville Speech & Hearing Center 12.19.14

I HEREBY AUTHORIZE PAYMENT OF MEDICAL BENEFITS RENDERED TO ME BY JACKSONVILLE SPEECH & HEARING CENTER:

PRINT NAME SIGNATURE DATE I HEREBY AUTHORIZE JACKSONVILLE SPEECH & HEARING CENTER TO RELEASE TO MY INSURANCE COMPANY ANY MEDICAL INFORMATION IN THE COURSE OF EXAMINATION AND/OR TREATMENTS. PRINT NAME SIGNATURE DATE

Jacksonville Speech & Hearing Center 12.19.14

Jacksonville Speech & Hearing Center, Inc.

Authorization for Use of Protected Health Information I authorize Jacksonville Speech & Hearing Center, Inc. administrative and clinical staff to:

- Use the following protected health information, and/or - Disclose the following protected health information to Physicians, or subcontracting parties

Jacksonville Speech & Hearing Center may utilize in the course of providing treatment:

• Audiograms and other audiological information • Evaluation results and other Speech/Language Pathology information • General Health Observations • Personal Information such as Name and Date of Birth • Contact Information such as Address, Telephone Number and Email Address • Hearing aid Serial Number

This protected health information is being used or disclosed for the following purposes:

• To aid in the treatment of me as the patient. • To contact me regarding events or contributions related to the Jacksonville Speech & Hearing Center.

This authorization shall be in force and effect for a period of 5 years at which time this authorization to use or disclose this protected health information expires. I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to Jacksonville Speech & Hearing Center, Inc. 1128 Laura Street, Jacksonville, FL 32206. I understand that a revocation is not effective to the extent that Jacksonville Speech & Hearing Center has relied on the use or disclosure of the protected health information or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. I understand that Jacksonville Speech & Hearing Center will not condition my treatment on whether I provide authorization for the requested use or disclosure. I have read and/or received a copy of the Jacksonville Speech & Hearing Center’s Notice of Privacy Practices. ______________________________ ______________________________ Signature of Patient or Personal Representative Date _________________________________ ______________________________ Print Name of Patient and/or Personal Representative Relationship to Patient [Copy will be provided at request of patient]

Jacksonville Speech & Hearing Center 12.19.14

PATIENT NAME: ____PATIENT D.O.B: CONSENT FOR CARE AND TREATMENT: I agree and consent to receive services according to the applicable standards of care used for evaluation or treating my child’s condition. I hereby release Jacksonville Speech & Hearing Center of any responsibility for my personal property I choose to bring to therapy. RELEASE OF MEDICAL INFORMATION: I authorize Jacksonville Speech & Hearing Center to release the medical records concerning my son/daughter/self to any physician, hospital, or agency involved in the care of the patient listed. ASSIGNMENT OF MEDICAL BENEFITS: I authorize my insurance carrier to assign all medical benefits, if applicable, to Jacksonville Speech and Hearing Center. I also authorize release of medical information necessary to process all medical insurance claims. PAYMENT POLICY: Co-payments are to be collected at the time services are received. We accept cash, checks, Visa, MasterCard, and Discover cards. All medical services provided are directly charged to the patient or responsible party. If our Center is contracted with your insurance carrier, we will accept their negotiated rate for the charges billed. However, you will be responsible for any balance deemed patient responsibility/non-payable/non-covered by your insurance and billed accordingly. Payment is expected in full upon receipt of statement or payment arrangements must be made with our billing office. CANCELLATION POLICY: Our office requests that if an appointment needs to be cancelled that we receive notice no later than 24 hours prior to the appointment. We reserve the right to charge $25.00 for a “no show” appointment, to be collected on or before your next appointment. REFERRAL POLICY: I understand that it is my responsibility to obtain a referral through my primary care physician’s office if required by my insurance company. Failure to do so will result in charges being billed directly to myself. I HAVE READ, UNDERSTAND, AND AGREE TO ABIDE BY THE ABOVE RELEASE OF MEDICAL INFORMATION AND PAYMENT POLICIES. X X Signature of Patient/Responsible Party Date read and signed

Photography/Audio Release – I do hereby grant and convey unto Jacksonville Speech and Hearing Center, Inc. all rights, titles, and interest in, and to any photographic images, video or audio recordings, promotional videos, slide presentations, advertising or brochure publications, mailings, social media and/or internet web pages containing my image or voice, without compensation or remuneration to me, made by or on behalf of Jacksonville Speech and Hearing Center, Inc. during my participation in volunteering or interning, or with any project, activity, or event sponsored, managed, arranged, or promoted by, or otherwise affiliated or associated with Jacksonville Speech and Hearing Center, Inc., including, but not limited to, any royalties, proceeds, or other benefits derived by Jacksonville Speech and Hearing Center, Inc. from such photographs or recordings.

_____Check here if you do not want to receive emails from Jacksonville Speech & Hearing Center. _____Check here if we do not have your permission for photographs, audio-visual recordings.

Jacksonville Speech & Hearing Center 12.19.14

AUDIOLOGY CHILD CASE HISTORY

Child’s Name: ________________________ DOB: ____________ Date: Parent(s)/Guardian(s) Names: Relationship to child: Referring Physician: Primary Concern: 1. Has your child experienced any ear infections? r Yes r No If yes, how frequently?

When was the most recent infection? _________________Treatment? ______________

2. Has your child ever been seen by an ENT (ear, nose & throat) physician? r Yes r No If yes, physician name: _____________________________ When: _________________ Concern at the time: _______________________________________________________ 3. Has your child ever had ear surgery? r Yes r No If yes, describe: ___________________________________________________________ 4. Has your child ever had a diagnostic hearing test in the past? r Yes r No If yes, when? __________________ Results? __________________________________ 5. Did your child pass a hearing screening in the hospital when born? r Yes r No 6. Is there a history of hearing loss in the child’s family? r Yes r No If yes, who? ______________________________________________________________ 7. Please mark (X) if your child has experienced any of the following:

r Academic difficulty r Difficulty with directions r Swimmer’s ear r Often asks for repetition r Difficulty following stories r Wax accumulation r Hyperactivity r “Hears but does not listen” r Balance difficulty r Sensitive to loud noises r Speaks loudly r Hears noises in the ears r Short attention span r Drainage from ear r Failed hearing screening

r Diagnosed ADD/ADHD r Ear pain r Known behavioral problems 8. Were there any complications during either birth or pregnancy? r Yes r No If yes, describe: _________________________________________________________________

Jacksonville Speech & Hearing Center 12.19.14

AUDIOLOGY CHILD CASE HISTORY (page 2)

9. Was your child born prematurely? r Yes r No If yes, how many weeks? ____________________ Birth weight: ________________ If known, what were your child’s APGAR scores? _____________________________ 10. Are there any known genetic disorders within the child’s family? r Yes r No If yes, describe: _________________________________________________________________ 11. Do you have any concerns regarding your child’s speech and language development? r Yes r No If yes, describe: __________________________________________________________________ Has your child been evaluated yet for this concern? r Yes r No Is your child receiving speech therapy? r Yes r No 12. Does your child have any other developmental difficulties? r Yes r No If yes, please describe: _____________________________________________________________ 13. Please mark (X) if your child has experienced any of the following: r Hyperbilirubin/Jaundice r Asphyxia r Congenital Infections r Bacterial Meningitis r Mechanical Ventilation r Fetal Alcohol Syndrome r Fever over 104° r Kidney problems r Heart problems r Head/Neck abnormalities r Seizures r Blood transfusion r Maternal substance abuse r Environmental allergies r Chemotherapy r Radiation r Other serious illness or accident 14. How did you hear about us: r Newspaper r Friend r Word of mouth r Relative r Health newsletter r Health fair screening r Web site r Doctor Referral r Yellow pages r Post Card r Other__________________ è ______________________________________ ___________________ Signature of person completing history Date è ______________________________________ Relationship to patient