Bloom Pediatrics
Nature. Nurture. Bloom.
IMG_0071.jpg

Parenting Support Group

PARENTING SUPPORT GROUP REGISTRATION

Group Dates *
Groups are limited to 10 participants. If a group is full, you will be notified via email and placed on a waiting list.
PARTICIPANT INFORMATION
Caregiver #1 Name *
Caregiver #1 Name
Caregiver #1 Phone *
Caregiver #1 Phone
Caregiver #1 Address *
Caregiver #1 Address
Caregiver #2 Name (Optional)
Caregiver #2 Name (Optional)
Caregiver #2 Phone (Optional)
Caregiver #2 Phone (Optional)
Group Participants *
Who is registering for this group?
CHILD INFORMATION
Child #1 Name *
Child #1 Name
Child #1 Date of Birth *
Child #1 Date of Birth
Child #2 Date of Birth
Child #2 Date of Birth
ADDITIONAL INFORMATION
REQUIRED FORMS
Financial Agreement *
Payment in full is due upon registration. 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. 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.
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 private health information (PHI) will be protected in his/her medical records, in consultation with other professionals involved in your care and with payers, HIPAA requires that your PHI be kept private and that you are notified of the privacy practices with respect to your PHI. A summary of the policies follows. MEDICAL INFORMATION Your 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, etc.) COLLECTION, STORAGE, DISCLOSURE AND DISPOSAL OF MEDICAL INFORMATION • Your 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 records may also be stored in a computer only accessible to your therapist(s). 
 • Correspondence with others regarding your PHI will only include other members or your current healthcare provider team to discuss your course of treatment. 
 • At your request, correspondence with outside consultants or personnel will be made. Your written consent is required for this communication to take place. • All phone correspondence with other members of your 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 you will include a fax coversheet with a confidentiality statement. No confidential information about you 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 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 therapist is your Privacy Officer. Each therapist is responsible for protecting your PHI and following these guidelines. 
 • Your 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 personal health information. The request must be made in writing. 
 • Your 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.
Confidentiality Agreement *
Confidentiality is the shared responsibility of all group members and facilitators. Although group facilitators will not disclose group communications or information, group members’ communications and information are not protected. Thus, this agreement is an attempt to provide you and your fellow group members with as much confidentiality protection as possible.
PAYMENT INFORMATION
Payment in full is due upon registration. 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.
Method of Payment *
NO CHARGES WILL BE MADE UNTIL REGISTRATION IS CONFIRMED WITH BLOOM.
Name on Card *
Name on Card
Today's Date
Today's Date
Payment Authorization