SUMMER CAMP 2019
Camp is held Monday-Friday from 9am-12pm unless otherwise specified.
I am interested in registering my child for the following dates:
Monday-Friday, July 1-5 (no camp on Thursday 7/4), $600 *FULL - JOIN WAITLIST*
Monday-Friday, July 8-12, $750 *FULL - JOIN WAITLIST*
Monday-Friday, July 15-19, $750 *FULL - JOIN WAITLIST*
Monday-Friday, July 22-26, $750 *FULL - JOIN WAITLIST*
Monday-Friday, July 29-Aug 2, $750 *FULL - JOIN WAITLIST*
Monday-Friday, Aug 5-9, $750 *FULL - JOIN WAITLIST*
Monday-Friday, Aug 12-16, $750 *FULL - JOIN WAITLIST*
Monday-Friday, Aug 19-23, $750 *FULL - JOIN WAITLIST*
Monday-Friday, Aug 26-30, $750
Tuesday-Friday, Sept 3-6 (no camp on Monday 9/2), $600
* Parent Name
Please list the best days and times to reach you.
Please let us know how you were referred.
Parent #2 Name (Optional)
Parent #2 Name (Optional)
Parent #2 Email Address (Optional)
Parent #2 Phone (Optional)
Parent #2 Phone (Optional)
* Child Name
Date of Birth
* Date of Birth
School of Attendance
What would you like us to know about your child?
What do you hope your child will gain from this program?
REQUIRED FORMS: PLEASE READ CAREFULLY
Attendance and Financial Agreements
$100 PER WEEK REGISTERED NON-REFUNDABLE DEPOSIT is due upon registration to hold your child’s spot, which will be charged to the credit card you provide below once registration is confirmed, unless prior alternate arrangements have been made (i.e., cash, check, Venmo@bloompediatrics, or PayPal.me/BloomPediatrics). Credit card information is required for security of payment.
Your credit card will NOT be charged if you are placed on a waiting list. If a space becomes available for your child, Bloom will contact you to confirm your registration.
PAYMENT IN FULL IS DUE WHEN INVOICE IS RECIEVED 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 with Venmo @bloompediatrics, PayPal at paypal.me/BloomPediatrics, or online using a credit card. DUE TO SCHEDULING CONSTRAINTS, WE CANNOT OFFER REFUNDS, MISSED SESSIONS CANNOT BE RESCHEDULED, AND FEES CANNOT BE PRORATED.
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, text, or other form of communication you have arranged as a point of contact if you need to cancel or are going to be late.
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. 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.
By checking this box, I attest that I have read, understand, and agree to the terms of the financial responsibility policy as detailed above.
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.
I give permission that my child may engage in the various therapeutic activities described above.
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
If your child exhibits or develops any of the above symptoms during a session, the session will be ended and the caregiver or emergency contact will be immediately contacted to pick them up.
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.
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.
I acknowledge and accept the terms of the above policies.
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.
I give consent
I do not give consent
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.
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.
I have read the above information and understand it.
I would like a copy of this privacy protection statement.
I would not like a copy of this privacy protection statement, but realize that this is available for review in my child’s medical record and I may request a copy in the future.
* EMERGENCY CONTACT
Please list someone other than a parent.
Relationship to Child
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.
I authorize permission for Bloom Pediatrics to exchange information, both oral and written, with the individuals or organizations listed below for the purpose of coordinating intervention. This information will only be released upon parent/legal guardian request.
Relationship to Child
PAYMENT INFORMATION: PLEASE READ CAREFULLY
$100 PER WEEK REGISTERED NON-REFUNDABLE DEPOSIT is due upon registration to hold your child’s spot, which will be charged to the credit card you provide below once registration is confirmed, unless prior alternate arrangements have been made. DUE TO SCHEDULING CONSTRAINTS, WE CANNOT OFFER REFUNDS, MISSED SESSIONS CANNOT BE RESCHEDULED, AND FEES CANNOT BE PRORATED.
Name on Card
* Name on Card
Billing Zip Code
Thank you! You will receive registration or waitlist confirmation and additional camp information via email within 24-48 hours.
Please keep in mind that your child’s spot is not confirmed until $100 per week non-refundable deposit has been made. Payment in full is due before first day of attendance. Due to scheduling constraints, missed sessions cannot be rescheduled and fees cannot be refunded or prorated.
If camp is listed as FULL, you will be placed on a WAIT LIST. Your credit card will NOT be charged to be placed on the wait list. If a spot becomes available, Bloom will contact you to confirm registration.