PEDIATRIC BILINGUAL HEALTH DEVELOPMENT & LANGUAGE QUESTIONNAIRE
WITH WHOM CLIENT LIVE?:(CON QUIEN VIVE EL CLIENTE)
Which of the following illnesses does your child have: (De las siguientes enfermedades cuáles tiene su niño/a:
It is the office policy of MD Therapy Solutions LLC, not to release confidential & or unauthorized
When returning telephone calls & a voice service picks up we will not leave a message if the name or
telephone number is not on the record voice service to identify the residence. Information will also
not be left with an unauthorized who may answer the telephone . If you require a healthcare
information to be released to someone other than yourself, please complete the following:
I authorize MD Therapy Solutions LLC, to leave medical information pertaining to my care by the
following methods and will assume responsability to notify them whenever this information changes.
Please list names of authorized people:
Patient Rights & Complaint Process
I understand that I have right to refuse treatment at any time. I have the right to review my records, diagnosis &
tratment plan. I understand that if I feel that my rights have been violated, it is my right to file a complaint with
the State of Florida.
I certify that I have read & understand the above & I accept all specified terms & fees therein & have received
information on patient rights including the process for initiation, review & resolution of complaints.
HIPPA Compliance Notification for Our Patients
The misuse of protected health information has been indentified as a national problem
causing some patient inconvenience, aggravation & costing them money. We want you to
know that our staff periodically receives training to assist them in understanding &
complying with government rules & regulations regarding the health insurance Portability &
Accountability Act (HIPPA) with a particular emphasis on the “Privacy Rule”.
We strive to achieve the highest standards of ethics & integrity in performing services for our patients.
When it is appropriate & necessary, we provide the minimum necessary information.
Others entities may have indirect treatment relationships with you (such as physician
reading your reports) & we may need to disclose personal health information for the
purpose of treatment or payment. These entities are most often nor required to have
You may refuse, in writing the consent to disclose your personal information. Under the
law, we then have the right to refuse to treat you, should you refuse to disclose your
personal health information. However you cannot revoke actions that have already been
taken which relied on this or any previously signed consent.
It is our policy to determine appropriate uses of personal health information in accordance
with the government rules, laws and regulations. We want to make sure that our office
never contributes to the growing problem of improper disclosure of personal health
information. We have implemented a program we believe will help us prevent inappropriate
use of personal information.
We also know that we are not perfect, because of this fact our policy is to listen to our
patients & employees without any thought of penalty if they feel that an event in any way
compromises our policy or integrity . More so, we welcome your input regarding any service
problem so that we may remedy the situation promptly . If you have any questions please
ask to speak with any one of our staff concerning the problem.
Parents release form for Picture and / or Media Recording
I, the undersigned, do herby grant or deny permission to
MD Therapy Solutions LLC, to use the image of my child:
, as marked by my selection
below. Such use includes the display, distribution, publication, transmission or otherwise
use of photographs, images, and/ or video taken of my child for use in materials that
include, but may be limited to, printed materials such as brochures and newsletters, videos,
and digital images such as those on a website.
In unusual circumstances, it may be necessary for a therapist/ employee to physically
restrain a patient in order to protect the patient and any other person form physical injury, or
to protect property from serious damage if a child becomes aggressive.
Be aware that as the child’s parent (s) you are always in charge of termination of your
As the parent of:
, I agree that MD Therapy Solutions LLC, and its employees shall not be liable for any damages and/or loss.
I hereby verify by my signature below that I fully understand and accept the above
Food/Treats are often used as positive reinforcements for activity completion. We would
like to guarantee that we are adhering to your child/ children’s diet or possible food
allergies. Please fill out this form so that we may do so.
Please feel free to bring in your own reinforcements from home.
Thank you for you cooperation.
The following form is a description of your good faith and veracity in all its details- Sending this form will be considered final before our consideration, therefore we recommend that you verify in detail that all the information is correct without omission in any line. Sending it is your acceptance of our terms and conditions. Thanks.