Patient Registration Form

All fields marked with * are required.

Please fill out this form to the best of your ability. If you have any questions, please call us at 910-673-5437.

Patient Information

Consent for Treatment:

I do hereby consent for treatment by Moore Pediatric Therapy Services I consent to the care and treatment falling under the practice guidelines of the American Occupational Therapy Association (AOTA), the American Speech-Language-Hearing Association (ASHA), the American Physical Therapy Association (APTA) and the state of North Carolina. I acknowledge that there is always a risk of injury with any therapy involving physical activity. I hereby, intending to be legally bound, waive forever all claims for damages against Moore Pediatric Therapy Services, the owner(s), and the employees for any and all injuries and losses, including theft, loss of property, or death that I, my son, daughter, or ward may sustain while participating in any and all activities at Moore Pediatric Therapy Services

By signing this form, I acknowledge that I have read and understand the contents and am competent to execute it, or if executed on behalf of another, that I am authorized to execute it on the behalf of that person.

Release of Medical Information:

I authorize Moore Pediatric Therapy Services to release necessary and pertinent medical information to physicians, case managers, insurance companies, Medicaid and the child’s school as needed for my child

I authorize Moore Pediatric Therapy Services to obtain pertinent medical information from the patient’s physician, therapists, case managers and insurance companies as needed.

Client Authorization for Emergency Medical Treatment:

In the event emergency medical treatment is required due to illness or injury during the process of receiving therapy, I authorize Moore Pediatric Therapy Services to:
1. Secure and retain medical treatment and transportation if needed.
2. Release client records upon request to the authorized individual or agency involved in the emergency treatment.

Financial Responsibility:

You could have chosen any number of therapy clinics; we thank you for choosing us! Effective January 1, 2015: We are happy to assist you in obtaining the maximum insurance benefits that your policy provides. As a courtesy to our patients, we will file your insurance and send any required supporting documentation.

-I agree to be responsible for payment of all services rendered on my behalf or to my dependents.

-All accounts with NSF/returned checks will have a $35 per check fee applied I hereby authorize Moore Pediatric Therapy Services to bill my insurance company for direct reimbursement of therapy services rendered to my child. I agree to pay the unpaid balance within 30 days after receipt of invoice from Moore Pediatric Therapy Services * Please be aware that some and perhaps all of the services provided may be “non-covered” services with your insurance company. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. In the event your insurance company denies coverage, you will be responsible for payment of all charges. You may choose to appeal the decision by your insurance company; however, we require that you pay the balance of the account within 30 days of receipt of invoice from Moore Pediatric Therapy Services.

I understand if I have an unpaid balance to Moore Pediatric Therapy Services and do not make satisfactory payment arrangements, my account may be placed with an external collection agency. I will be responsible for reimbursement of any fees from the collection agency, including all costs and expenses incurred collecting my account, and possibly including reasonable attorney’s fees if so incurred during collection efforts.

In order for Moore Pediatric Therapy Services or their designated external collection agency to service my account, and where not prohibited by applicable law, I agree that Moore Pediatric Therapy Services and the designated external collection agency are authorized to (i) contact me by telephone at the telephone number(s) I am providing, including wireless telephone numbers, which could result in charges to me, (ii) contact me by sending text messages (message and data rates may apply) or emails, using any email address I provide and (iii) methods of contact may include using pre-recorded/artificial voice message and/or use of an automatic dialing device, as applicable.

Attendance Policy:

Moore Pediatric Therapy Services requires a 24-hour notice when you need to cancel an appointment. If you fail to give this notice, a cancellation fee of $40 dollars will be charged to you after a one-time warning. It is understood that there are emergency situations and sicknesses that will occur and this will be handled on a case by case basis. If three consecutive sessions of therapy are missed, it is possible that a new therapy time will need to be arranged or you may be discharged from services. We hope to be able to find times that suit everyone’s needs.

Sickness Policy:

All of our therapists work with medically fragile children and we don’t want to carry sickness to other families, infect ourselves, or our own families. Please be respectful and cancel your therapy appointment if your child is sick. You will not be charged a cancellation fee for sickness.

The Board of Health considers the following signs to indicate communicable disease/illness:

  • Vomiting
  • Fever over 100 degrees
  • Diarrhea
  • Sore throat
  • Rash
  • Red running eyes
  • Lice

Please be sure your child is symptom free for 24 hours before resuming therapy. Thank you.

Discharge Policy: :

Patients will be discharged from therapy services when:

  • The patient’s guardian declines assessment and/or treatment
  • The patient’s guardian requests discharge and/or transition
  • The patient’s primary care provider declines signing off on Dr orders;
  • The patient achieves functional treatment goals or has achieved maximum benefit from therapy.
  • The patient is unable to progress towards anticipated goals and/or expected outcomes because of medical/psychosocial complications;
  • The patient is being transferred to another agency (transition of services);
  • The patient fails to uphold attendance regulations;
  • The patient’s guardian is unable to be reached despite continued efforts;
  • The patient moves away;
  • The patient or guardian doesn’t follow clinic standards/practices;
  • The patient has been "on hold" for more than two weeks with no explanation;
  • Treatment services are not available;
  • At the discretion of the practice, due to any circumstances that impedes with therapy and safety of all.

In all cases, you will be kept informed of any plans to discharge or transition your child’s services. In many cases, children may be re-referred for particular services as their needs or circumstances change.

Notice of Privacy Practices:

In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services and to conduct health care operations involving our office.

The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. You are free to refer to this notice at any time before you sign this form. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and service provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes (1) our submission of your health information to a billing agent or vendor for processing claims or obtaining payment; (2) our submission of claims to third-party payers or insurers for claims review, determination of benefits and payment; (3) our submission of your health information to auditors hired by third-party payers and insurers; and (4) other aspects of payment described in our Notice of Privacy Practices.

When you sign this consent document, you signify that you agree that we can and will use and disclose your health information to treat you, to obtain payment for our services and to perform healthcare operations. You also signify that you have been given the opportunity to read our Notice of Privacy Practices. A copy is available upon request. You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment or healthcare operations, but as described in our Notice of Privacy Practices , we are not obliged to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.

I have read this document and understand it. I consent to the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations. I acknowledge that I have received the Notice of Privacy Practices from Moore Pediatric Therapy Services.


I understand I have the right to refuse to sign this form, and that I may revoke my consent at any time (except to the extent that the information has already been released).