Bloom Pediatrics
Nature. Nurture. Bloom.
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Camp Registration

CAMP REGISTRATION 2018-19

WINTER CAMP 2018-19
I am interested in registering my child for the following dates:
PARENT INFORMATION
Parent Name *
Parent Name
Phone *
Phone
Address *
Address
Parent #2 Name (Optional)
Parent #2 Name (Optional)
Parent #2 Phone (Optional)
Parent #2 Phone (Optional)
CHILD INFORMATION
Child Name *
Child Name
Date of Birth *
Date of Birth
ADDITIONAL INFORMATION
REQUIRED FORMS
ATTENDANCE AND FINANCIAL AGREEMENT *
$100 non-refundable deposit is due upon registration to hold your child’s spot. Balance is due one month before first day of attendance, unless prior alternate arrangements have been made. All invoices are sent via email. To keep the cost of services down, cash or check is the preferred form of payment. You may also pay online using a credit card. Bloom strives to provide quality services for your child. Regular attendance is necessary to establish a positive routine and to ensure progress is made toward your child’s goals. Please contact us directly via phone or other form of communication you have arranged as a point of contact if you need to cancel or are going to be late. Due to scheduling constraints, missed sessions cannot be rescheduled and fees cannot be prorated. By checking the box below, I acknowledge and understand that Bloom does not bill my insurance company and that I am financially responsible for the complete payment of all charges to Bloom at the time of service. I understand that I am obligated to pay for late cancellation fees, no show fees, and non-sufficient funds fees, and that these fees are not reimbursed by insurance companies. By checking the box below, I acknowledge and understand that a $35.00 service fee will be charged for any checks or payments returned for insufficient funds. I understand that finance charges will accrue at 12% APR if payment is not received in our office within 5 days of the due date, and a minimum monthly finance charge of $5.00 will apply to all overdue payments. I understand that if my account is 30 days past due, Bloom will automatically charge the credit card on file to cover my outstanding balance. Balances exceeding $1000.00 will result in services being placed on hold until a payment plan has been established. Bloom reserves the right to terminate treatment if payment for services is not received. Invoices more than 90 days past due are considered to be in default. I understand that I will be charged cost recovery fees if Bloom must take collection action to resolve payment delinquencies. Cost recovery fees may include small claims fees, attorney fees, enforcement fees, collections fees and lien fees.
CONSENT FOR USE OF EQUIPMENT *
In case of an emergency, I give permission to the personnel of Bloom, into whose care our child has been placed, the authority to consent to an x-ray examination, anesthetic, medical or surgical treatment and hospital care to be rendered under the supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medical or Dental Practice Act. In the event of a medical emergency I hereby understand that the staff of Bloom, will contact 911 or other appropriate medical personnel. If ambulance service must transport my child, I understand that it will be to the closest medical facility able to handle the situation. I understand that my child’s records are protected under state and federal confidentiality regulations and cannot be disclosed without prior written consent. By checking the box below, I acknowledge and give my consent to allow the release of information and/or records/reports regarding my child for purposes of emergency medical treatment. The staff of Bloom will not be liable for any first aid treatment, medical or hospital care rendered, or drugs, medicine or surgical procedures performed pursuant to this consent. I understand that my child will be involved in therapeutic activities which may involve the use of specialized equipment such as suspended equipment, swings, large therapy balls, tactile or touch media, gross motor, fine motor, and oral motor activities. I have been informed by the staff of Bloom regarding the nature of, as well as the risks associated with the use of this equipment and related activities.
SICK POLICY *
In consideration for the health of our clients, therapists and staff, we require that parents do not send their children if they exhibit any of the following: • Illness symptoms within the last 24 hours • Fever: temperature of 100° F or greater within the last 24 hours • Vomiting within the last 24 hours • Sore throat or difficulty swallowing • Mouth sores • Eye discharge • Unusual nasal discharge • Uncontrolled coughing • Difficulty breathing or wheezing • Wounds that are not properly covered SOILED CLOTHING If your child has child has soiled his or her clothing during a treatment session and does not have a proper change of clothes, the session will be ended. HEAD LICE Bloom supports the Head Lice Policy of the American Association of Pediatrics. If you know your child has live head lice, begin a treatment to kill live lice before coming to therapy. We advise seeking professional care of lice and nit removal. Your child must be cleared of nits and lice for at least seven days prior to returning to therapy clinic to support containment of lice and reduce risk of spreading to others and on therapy equipment.
COMMUNICATION AND CORRESPONDENCE *
We will share your child’s progress as well as discuss other information about your child after their session. We want to ensure your child’s privacy and be considerate of any confidential information that may be part of this discussion. Please check which methods of communication you feel are appropriate for conversation. If you select only the text message, phone and/or email options, we will end your child’s session a few minutes early to allow for adequate time to communicate with you. By checking the box(es) below, I agree that the methods of communication are acceptable for my child’s session wrap-up discussion. I understand I am responsible for additional data charges imposed by my service provider and acknowledge Bloom is not liable for any compromised privacy by my email provider/host, internet service, cell phone or data service.
VIDEO AND PICTURE CONSENT *
I hereby give my permission to Bloom to video and/or to take still photographs of my child for purposes related to therapy and treatment planning. The videos and/or pictures of my child will not be used for any other purpose. I understand that any videos and pictures are the property of Bloom, but that I may ask for copies for my own use. If I choose to decline permission now or to revoke my permission at any time in the future, I may do so without any impact on my child's care at Bloom. If I wish to revoke my permission in the future, I will submit my request in writing to Bloom. I understand that there will be no adverse effects of photographing or filming my child, and that if my child chooses not to cooperate with filming, the process will be terminated.
SOCIAL MEDIA AND WEB CONSENT *
I agree to have my child’s photographs to be displayed on Bloom's website and social media in order to share my child’s accomplishments and demonstrate the work done at Bloom. I release Bloom, its parent, affiliates, officers, directors, agents and employees, and those acting under its authority, from all debts, claims and liabilities of any kind arising out of or in connection with the use and publication of the photograph/ likeness referred to above. I hereby agree to hold Bloom, its parent, affiliates, officers, directors, agents, and employees, and those acting under its authority, against loss from any claim, action, or demand that may be brought at any time by the above-named minor or by anyone acting on the minor’s behalf for the purpose of enforcing a claim for damages on account of the use and publication of the minor’s likeness and photograph.
HIPAA NOTICE OF PRIVACY POLICIES *
HIPAA NOTICE OF PRIVACY PRACTICES In compliance with the Health Insurance Portability and Accountability Act’s Privacy Rule (HIPAA), your child’s private health information (PHI) will be protected in his/her medical records, in consultation with other professionals involved in your child’s care and with payers, HIPAA requires that your child’s PHI be kept private and that you are notified of the privacy practices with respect to your child’s PHI. A summary of the policies follows. MEDICAL INFORMATION Your child’s PHI may consist of evaluations, diagnosis, daily notes, progress notes, Individual
Family Service Plan (IFSP) Individualized Educational Plan (IEP), insurance information, physician prescriptions, and correspondences to your other medical and educational providers (e.g., physician, therapists, service coordinators, psychologists, social worker, school personnel, etc.) COLLECTION, STORAGE, DISCLOSURE AND DISPOSAL OF MEDICAL INFORMATION • Your child’s records will be kept in a file with his/her name on it. These files are stored in a locked container in your therapist’s home office or in a central file at our office. Your child’s records may also be stored in a computer only accessible to your child’s therapist(s). 
 • Correspondence with others regarding your child’s PHI will only include other members or your current child’s healthcare provider team to discuss your child’s course of treatment. 
 • At your request, correspondence with outside consultants or educational personnel will be made. Your written consent is required for this communication to take place. • All phone correspondence with other members of your child’s healthcare team or payer will be conducted on a private phone line in a confidential manner, so others cannot hear the conversation. 
 • All faxed information about your child will include a fax coversheet with a confidentiality statement. No confidential information about your child will be included on the fax cover sheet. 
 • Correspondence by mail will be addressed to specific individuals for the purpose outlined above. 
 • A written record of all disclosures of your child’s PHI will be kept. 
 • Only the Minimum Necessary Requirements will be disclosed to the entity requesting information. This means that only the minimum amount of information necessary to complete the task for which the entity is requesting the information will be provided, rather than sending the entire le. 
 • Your child’s therapist is your child’s Privacy Officer. Each therapist is responsible for protecting your child’s PHI and following these guidelines. 
 • Your child’s records will be kept and stored for a minimum of 6 years. After this time, the records will be shredded to protect privacy. YOUR RIGHTS UNDER HIPAA • You have the right to inspect and copy your child’s personal health information. The request must be made in writing. 
 • Your child’s PHI will be used strictly for evaluation and treatment planning. 
 • You have the right to request information about who PHI has been released to. 
 • You have the right to take away permission to disclose information to any party at any time. This request must be made in writing. • You have the right to complain if you believe your privacy rights have been violated. if you feel your rights have been violated, please contact us. You may also file a complaint with the U.S. Department of Health and Human Services Office of Civil Rights at hhs.gov/ocr/privacy/hipaa/complaints/, 877.696.6775, or U.S. Department of Health and Human Services, Office of Civil Rights, 200 Independence Avenue, SW; Washington, D.C., 20201. We will not retaliate against you for filing. SUMMARY OF RESPONSIBILITIES We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We will give you a hard copy of this notice and follow the duties and privacy practices described in this notice. We will not use or share your information other than as described here unless you tell us in writing that we can. You may also change your mind at any time and let us know in writing if you do. Additional information is available at hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html TERMS OF CHANGE We can change the terms of this notice. Any changes to this notice will be available to you upon request, on our website, or office. These changes will apply to your information we have on file.
EMERGENCY CONTACT *
EMERGENCY CONTACT
Please list someone other than a parent.
Phone *
Phone
AUTHORIZATION TO RELEASE INFORMATION
Since all communications made within the confines of a therapeutic relationship are confidential, it is necessary for this office to request a signed authorization in order to exchange any information related to this type of confidential relationship. This release of information may be revoked at any time through a signed statement and will expire one year from the date of authorization.
Phone
Phone
Today's Date
Today's Date
PAYMENT INFORMATION
$100 non-refundable deposit is due upon registration to hold your child’s spot. Balance is due one month before first day of attendance, unless prior alternate arrangements have been made. All invoices are sent via email. To keep the cost of services down, check is the preferred form of payment. You may also pay online using a credit card, or have us charge the credit card on file.
CREDIT CARD *
NO CHARGES WILL BE MADE UNTIL REGISTRATION IS CONFIRMED WITH BLOOM. Check is the preferred form of payment. Credit card information must be provided for security of payment to Bloom.
Name on Card *
Name on Card
Payment Authorization