Spectrum of Hope Initial Visit Documentation Form

Thank you for choosing Spectrum of hope to your child's/ youth's developmental journey.
Please complete the form below to schedule your initial visit. It is impotant that we obtain as much information form you as possible to provide the most holistic care.
Please give yourself at least 45-60 minutes to complete this form and upload all required documentation.
Thank you!

Child/ Youth Information

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Parent Information

Treatment and Insurance Authorization/ Payment Policy

TREATMENT AUTHORIZATION
 
Authorization is hereby granted for my child/children to have diagnostic evaluations, medical consultation, examinations, routine-screening procedures as recommended by Spectrum of Hope- Health, Wellness and Community Services, LLC (SOH) in partnership with the following entities:
 
1. Heritage Care Inc. is a Hyattsville, Maryland non profit that provides commuity services in the areas of healthcare and education. 
 
2. RSI - Rehabilitation Services, Inc is a Laurel, Maryland therapy center which provides comprehensive care for acute injuries, chronic conditions, and developmental impairments for clients of all ages. 
 
This authorization shall be continuous unless revoked by you, parents or guardian, I also authorize Spectrum of Hope- Health, Wellness and Community Services, LLC (SOH) to initiate any medical treatment required in an emergency.
 
INSURANCE AUTHORIZATION AND ASSIGNMENT OF BENEFITS
 
I hereby authorize Spectrum of Hope- Health, Wellness and Community Services, LLC (SOH) and its partners:
 
1. Heritage Care Inc. is a Hyattsville, Maryland non profit that provides commuity services in the areas of healthcare and education. 
 
2. RSI - Rehabilitation Services, Inc is a Laurel, Maryland therapy center which provides comprehensive care for acute injuries, chronic conditions, and developmental impairments for clients of all ages. 
 
, to directly receive payment of pertinent insurance benefits; to release information including protected health information to insurance companies and other related third parties as needed in relation to the filing for or collection of payment for provided services; to obtain records from other sources as needed in relation to patient diagnosis and treatment; and to convey information through various means as needed in accordance with the Notice of Privacy Practices, a copy of which was made available to me.

I acknowledge that I must give a 24-hour notice to cancel an appointment. If I do not call within 24 hours of my appointment, a $35.00 charge (not billable to my insurance) will be billed to my account (unless Medicaid). I understand that this fee must be paid before I reschedule any appointment.

I hereby acknowledge that I am personally responsible for all co-payment, deductibles, non-covered services and required referrals according to my insurance policy. I agree to pay all applicable charges accrued and to promptly pay any balance in full. I understand that my account will be charged $35.00 for any checks returned due to non-sufficient funds.
 
I also agree that I am responsible for any collection and/or attorney fees. I agree that I am responsible to promptly alert Spectrum of Hope- Health, Wellness and Community Services, LLC (SOH) and its partners:
 
1. Heritage Care Inc. is a Hyattsville, Maryland non profit that provides commuity services in the areas of healthcare and education. 
 
2. RSI - Rehabilitation Services, Inc is a Laurel, Maryland therapy center which provides comprehensive care for acute injuries, chronic conditions, and developmental impairments for clients of all ages. 
 
should there be any changes related to insurance and other information I provided above. A photocopy of this assignment shall be valid as the original. I certify that the information I have provided is current and correct. Either my insurance carrier or I may revoke this authorization at any time in writing.
 
PAYMENT POLICY
I understand and agree that, (regardless of my insurance status) I am ultimately responsible for the balance of my child’s/children’s account for all professional services rendered. I have read all the information and certify that the information I have provided Spectrum of Hope- Health, Wellness and Community Services, LLC (SOH) and its partners:
 
1. Heritage Care Inc. is a Hyattsville, Maryland non profit that provides commuity services in the areas of healthcare and education. 
 
2. RSI - Rehabilitation Services, Inc is a Laurel, Maryland therapy center which provides comprehensive care for acute injuries, chronic conditions, and developmental impairments for clients of all ages. 
 
is true and correct. I will notify this office of any changes in my child's/children’s health status or the above information.
 
 
Signature of Parent/ Guardian *
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Pharmacy Information

Educational Release/ Exchange

EDUCATIONAL RELEASE/EXCHANGE:
 
I Hereby give permission to Spectrum of Hope- Health, Wellness and Community Services, LLC (SOH) to release information and/ or exchange information with the educational team for the mentioned school/educational placement stated below.
Signature of Parent/ Guardian *
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Telemedicine Consent

By signing this form,

I understand that all the laws that are protecting my privacy of medical history or information are also applied to telemedicine practices.

I understand that I can withdraw the consent at any time and that will not affect any of my future treatment procedures.

I understand that I can be charged the additional fees that my insurance does not cover.

I accept that I authorize health care professionals and use telemedicine for my treatment and diagnosis.

Signature of Parent/ Guardian *
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HIPAA Notice of Privacy

HIPAA NOTICE OF PRIVACY

Spectrum of Hope- Health, Wellness and Community Services, LLC (SOH) has implemented the following policies and procedures to ensure the confidentiality of your personal and/or medical information. Federal and state laws require us, to maintain the privacy of your health information.
Your provider(s) and all other employees working at Spectrum of Hope- Health, Wellness and Community Services, LLC (SOH) will keep any information related to you (medical and/or non-medical) in a confidential manner. However, so that we may provide you with appropriate medical care, for general practice operations and or for the purposes of obtaining payment, we will, at our discretion provide information pertaining to the treatment you received at Spectrum of Hope- Health, Wellness and Community Services, LLC (SOH), the charges for this treatment and related information regarding the treatment and charges to other health care related entities. This information will be submitted through the following mechanisms: US Postal Service, fax submission, Internet submission, voice mail and/or personal communications. The following is a list of the most common types of entities that we most typically would provide personal health related information. This list is not an all-inclusive list. Other entities may be added to this list.
▪ Physicians, non-physician providers that work outside of this practice.
▪ Other professionals providing support services related to your medical condition (i.e. community service/programs, health department services, educational services and nutritional counselors).
▪ Medical facilities (i.e. hospitals, outpatient centers).
▪ Laboratories for the purposes of running medical tests.
▪ Other health care providers, such as pharmacies, durable medical equipment suppliers, ambulance services.
▪ Insurance companies (or third-party administrators) for the purpose of obtaining payments, reviewing medical necessity and or general case management.
▪ State or Federal agencies that require the submission of specific health related information
▪ Billing services.
We may need to contact you, by phone, to discuss your appointments, test results, treatments, referrals, account balance and/or to return your phone call. We will first attempt to contact you at home, however if you are not available and you provide us with your work number, we will attempt to contact you at work. If you are not available, we will leave a message for you to either call the office for a specified reason (i.e. discuss test results, account balance) or we will remind you of your appointment time.
In the event you do not pay all your charges in full at the time of your visit, we will mail a statement to your home. Also, depending upon your situation, we may mail recall cards to your home noting that you need to contact the office to schedule an appointment. Periodically, we may mail test result information to your home. We will use the home address you provided us with at the time you register with the practice.
We may contact your insurance company to determine your coverage, eligibility, unmet deductible and/or your co-insurance and co-pay requirements. If necessary, for obtaining payment, we will provide credit bureaus and/or collection agencies with your account information.
When you arrive at our practice for your appointment, we will ask you to sign in and note your arrival time. We will do our very best to see you promptly. However, there may be times when your provider is running behind schedule and you will need to wait in the waiting room.
If you would like information sent to another physician or medical facility, you may be asked to authorize the release of this information, in writing (we will provide you with the necessary form to complete). Also, you must provide written authorization for the release of information to your life or disability insurer.
You may review and/or obtain a copy of your medical record. You may request, in writing, changes be made to your medical record. We will review your reason(s) for such a request and if we agree, will make the change(s). If we do not agree with your request, you are entitled to have your statement added to the record. Also, you may request information regarding who we have disclosed your medical information to for purposes other than treatment, payment and health care operations.
Please provide us with current phone numbers (work and home) and home billing address. This will allow us to make the correct contact when trying to reach you.
When necessary these policies will be modified to ensure compliance with practice operations and with State and Federal privacy regulations.
If you have any questions or concerns with the policies and/or procedures noted above, please contact our HPAA privacy officer at the above address and phone number to report any and all concerns. We trust that you are comfortable with our sincere efforts to maintain the confidentiality of the information related to your medical care. If you believe we have not maintained the privacy of your records, you may file a complaint with the Secretary of the US Dept. of Health & Human Services. There will be no retaliation for filing a complaint.
Signature of Parent/ Guardian *
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Provider Patient Agreement

Providing the best possible care to every patient is our primary goal. The only way we can meet this goal is if we work together in parent/professional partnership for the best interest of your child!

 

PATIENT’S CAREGIVER RESPONSIBILITIES:

  • Accompany child to all office visits or provide written consent authorizing responsible adult to stand in
  • Ask questions, share your feelings and be part of your child’s care
  • Be honest about history, symptoms, and other important information regarding your child’s health
  • Tell your doctor about any changes in your health and wellbeing
  • Give all medicine as directed and follow your doctor’s advice
  • Make healthy decisions about your daily habits and lifestyle choices as these too affect your child
  • Prepare for and keep scheduled visits or reschedule visits in advance whenever possible
  • End every visit with a clear understanding of the doctor’s expectations, treatment goals, and future plans

 

DOCTOR’S/ HEALTHCARE PROVIDER’S RESPONSIBILITIES:

  • Explain diseases, treatments, and results in an easy-to-understand way
  • Listen to parent/patients’ feelings and questions and help them make decisions about their care 
  • Keep treatments, discussions, and records private
  • Provide instructions on how to meet your health care needs when the office is not open 
  • Care for you to the best of our abilities based on understanding the current medical methods available
  • Give parents/patients clear directions about medicines and other treatments
  • Send our patients to trusted experts, and service providers when indicated
  • End every visit with clear instructions about expectations, treatment goals, and future plans

 

 

ARRIVAL TIME, AND LATE POLICY:

 

  • If you are a NEW patient for our Autism Specialist, we asked that you check-in no later than 40 minutes prior to your appointment time for insurance verification and completion of appropriate forms/surveys/questionnaires.
  • If you are an ESTABLISHED patient of our Autism Specialist, please check-in 30 minutes prior to your visit with our Autism Specialist for insurance verification and/or completion of appropriate forms, surveys and/or questionnaires.
  • When you are meeting with the Autism Specialist please plan and expect to spend up to 2 (two) hours.
  • If you are 15 minutes late for an Autism Specialist visit, your appointment will be rescheduled to the next available appointment or converted to a smaller more focused concern or task.

 

  • For MEDICAL OR PSYCHOLOGICAL EMERGENCIES please go to your nearest Emergency Room or call 911 if the patient is unstable.

 

INSURANCE AND PAYMENTS:

  • Insurance verifications are completed a week before your appointment and then again at your visit. You will not be seen if your insurance coverage has lapsed or become inactive. The appointment will be cancelled, but once your insurance becomes active, we are happy to attempt to reschedule your appointment.
  • A fee schedule will be available for uninsured clients who wish to be seen or for any out of pocket cost which are not covered by insurance.
  • Please be advised that ALL balances and co pays must be paid prior to any services being rendered.

 

CANCELLATIONS/ CLOSINGS:

  • We will make every effort to honor your appointment but in the event of inclement weather or other unforeseen emergency/conflict we will notify you of cancellation or close of business and make every effort to reschedule your visit in a reasonable amount of time.

 

REFILLS:

  • All prescription refill requests should originate from the patient by contacting their pharmacist asking to request the refill electronically. 
  • All refill requests should be approved or disapproved by our office in 72 hours or less.
  • The reasons for any disapproval will be given electronically through the pharmacy. Keep in mind, you may be asked to schedule an appointment prior to refill.
  • Routine prescription refills may not be filled after hours or during the weekends, so parents need to plan.

 

FORMS:

  • All forms will be completed within 7-10 business days from time of patient/parent drop off. Please be sure patient/parent information is filled out in its entirety prior to dropping off form and parent should allow for timely pick up to meet any deadline.
  • Patient may also schedule a visit for form completion such as sports PE, camp forms, preop exam, WIC, medication authorization, etc. but physician may require additional time if there are multiple forms or if it is a complicated matter or a lengthy task.
  • If a parent brings in a document for physician review, i.e. Vanderbilt’s, outside specialist’s notes, past medical records, school progress report, etc. the information becomes part of the patient’s medical record. Once reviewed by the physician, the office will contact you with any additional instruction on a case by case basis.

 

LETTERS:

  • In general, any request for a letter of medical support requires a visit to discuss the concern and observe/examine the child. The provider will gather the information necessary to determine whether it is a document he/she can provide and/or may suggest another option. Letters like forms, will also require several days for completion so parent should allot time appropriately.

AFTER-HOURS:

 If you feel that your child is having a life-threatening medical emergency, please go to the nearest hospital or call 911, if your child is in distress.

  • Questions for our Autism Specialist and/or issues related to Autism diagnostic clinic or its patients are also best handled during the day. These services are unavailable after- hours.
Signature of Parent/ Guardian *
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Email Consent

EMAIL CONSENT

I acknowledge that I have read and understand the items below which describe the inherent risks of using e-mail to communicate personally identifiable information.
  • Confidentiality and privacy – there’s a risk that emails set over the internet may be intercepted
  • Confirming your identity – It’s crucial that communications are with established contacts at their correct email addresses
  • There is no guarantee that any email received over an insecure network, like the internet, has not been altered during transit
  • Attachments could contain a virus or malicious code.
Nevertheless, l, the caregiver of the child/ youth identified above, authorize the staff and representatives of Spectrum of Hope Health, Wellness and Community Services with addresses (i.e.- staff or representative name @spectrum-hope.com) to communicate with me at my e-mail address. BY PROVIDING YOUR EMAIL YOU CONSENT TO EMAIL Communication

Additional Required Documents- Please upload






Child/ Youth Measurements

Developmental/ Behavioral Checklist

PEDIATRIC BEHAVIOR CHECKLIST Please indicate whether your child has or has difficulties with any of the following *
SOCIAL INTERACTIONS: Please indicate whether your child displays any of the following. *
RESTRICTED OR REPETITIVE PATTERNS OF BEHAVIOR: Please indicate whether your child displays any of the following. *
Family History: Please indicate if the following conditions are present in your child's/ youth's family history and in whom. *
 Absent in child/youth being evaluated and all family membersPresent in child/ youth being evaluatedPresent in siblingPresent in motherPresent in fatherMaternal family history (on mother's side of family)Paternal family history (on father's side of family)
Attention Deficit and/or Hyperactivity Disorder
Learning Disability
Intellectual Disability
Autism
Language Delay
Articulation or other Speech Challenges
Genetic Disorders (Down's, Fragile X)
Hearing Impairment
Vision Impairment
Seizures
High Blood Pressure
Heart Disease
High Cholesterol
Blood disorders (Sickle Cell, Thalassemias, Anemia)
Eczema or other skin, hair or nail disorders
Kidney Disease
Liver Disease
Gastrointestinal Disease/ Disorder
Diabetes
Autoimmune Disorder
Thyroid or other endocrine disorder
Cancer
Tics/ Tourette's Syndrome
Depression
Obsessive-Compulsive Disorder
Bipolar Disorder (Manic Depressive Illness)
Anxiety
Schizophrenia

Service Satisfaction Survey (OPTIONAL)

Please rate your satisfaction with obtaining our services: 1 star not satisfied...... 5 stars extremely satisfied.
1. Timeliness of our team in responding to your inquiry for service.12345
2. Friendliness of team members.12345
3. Overall, how satisfied are you with obtaining services for your child/ youth?12345
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