Today’s Date: _______________

WELCOME TO LEAPS & BOUNDS, PT!

Please fill in all paperwork completely and to the best of your knowledge.

Personal Information:
Patient’s Name: _________________________________________ DOB: _____________
Parent/Guardian’s Name: ____________________________________________________
Patient’s Home Address: _____________________________________________________
____________________________________________________________________________
Contact Phone Numbers: (home) _(_____)_____________________________________
(cell 1) __(_____)____________________ (cell 2) __(_____)_________________________

Referral Information:
Please tell us who referred you/how you heard about Leaps and Bounds?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Primary/Referring Physician’s Name: __________________________________________

Phone Number: __(____)____________________

Name and Phone Number of any additional Physicians the patient may visit:
_______________________________ ___(____)________________________
_______________________________ ___(____)________________________
_______________________________ ___(____)________________________
 IMPORTANT COMPANY POLICIES
Please initial each box.

Late policy – Being more than 15 MINUTES LATE for an appointment will require
rescheduling, or waiting until the next available opening. There are no guarantees the
patient will be seen that day, since cancellations are unpredictable. We do not allow
appointment overlap because this undeservedly compromises the care of both patients.

No shoes in therapy area – We have worked to create a sterile and sanitary

environment for your children to “play” in. Therefore, it is office policy that no shoes are
to be worn in the therapy area. We also do not permit bare feet. If you don’t have socks,
we can provide shoe covers for your convenience. There is a shoe rack located just past
the door where shoes can be stored during your child’s session.

Cell phone must be silent – We realize that an emergency may arise and you need
access to your cell phone. However, please be courteous and set it to silent mode or turn
it off during the session. If you must make a call, please step into the hallway.

Children require supervision at all times – All children require adult

supervision at all times, either with a parent or therapist. It is NOT appropriate to leave
children alone in the waiting area and it is NOT SAFE to allow them to roam the building
unsupervised. We encourage parents to be in therapy sessions whenever possible.
Siblings may join the patients in the therapy area if they can refrain from disrupting
treatment, of both their own sibling and any other children who may be receiving therapy
at that time. If patients do not do well with parents in the room, or if siblings are
distracting, please stay in the waiting area.

I have read and agree to all the above policies. I recognize that policies are
subject to change at the discretion of Leaps and Bounds, PT.

Parent/Guardian’s signature: __________________________________ Date: ____________

 Leaps and Bounds, PT

ASSIGNMENT OF BENEFITS
Primary Insurance:
Insurance Name: _______________________ Name of Policyholder: __________________________
Employer: _____________________________ Policyholder DOB: _____________________________
Relationship to Patient: ________________________

Secondary Insurance:
Insurance Name: _______________________ Name of Policyholder: __________________________
Employer: _____________________________ Policyholder DOB: _____________________________
Relationship to Patient: ________________________

I hereby instruct and direct _______________________ insurance company to pay by check made
out and mailed to:
Leaps and Bounds, PT
1931 Richmond Avenue, Suite 203
Staten Island, NY 10314
718-477-1911
If my current policy prohibits direct payment to doctor, I hereby also instruct and direct you to
make out the check to me, and mail it to the above address for the professional and medical
expense benefits allowable, and otherwise payable to me under my current insurance policy, as
payment toward the total charges for the professional services rendered.
This is a direct assignment of my rights and benefits under this policy.
This payment will not exceed my indebtedness to the above-mentioned assignee, and I have
agreed to pay, in a current manner, any balance of said professional service charges over and
above this insurance payment.
Please check each box and sign the bottom.
A photocopy of this Assignment shall be considered as effective and valid as the original.
I authorize the release of any medical or other information pertinent to my case to any
insurance company, adjuster, or attorney involved in this case for the purpose of processing
claims and securing payment of benefits.
I authorize Leaps and Bounds, PT to use this signature on all insurance submissions.
I authorize Leaps and Bounds, PT to deposit checks made in my name.
I authorize Leaps and Bounds, PT to complain to the Insurance Commissioner for any reason
on my behalf.
I understand that I am financially responsible for all charges that are paid out to me by
insurance.
Policyholder’s Signature: _______________________________ Date: _________________________
Office Staff Initials: _____
 INSURANCE INFORMATION
We are currently Out of Network with all insurance companies.

What does this mean for me?

Insurance company checks and EOBs (explanations of benefits) may be mailed straight to
your home. We will receive the information that you have been paid. If you don’t receive
anything, it is possible that checks have been mailed directly to our office.

What am I financially responsible for?

As a courtesy, Leaps and Bounds, PT will not collect in full the visit amount, as the
insurance company suggests we do. Instead, by signing this form, you agree to bring in all
complete EOBs and checks mailed to you. We require the policyholder to endorse the check, but
you do not have to cash it. Just bring it in at your child’s next visit, or mail it to us.

Why do I have different charges for each therapy visit?

Therapy is billed differently than most doctor visits. Instead of billing a single code for the
visit, we must bill for each procedure performed and by the amount of time that the procedure
was performed. This means that, on your explanation of benefits, it is normal to see four or five
billed codes. As for the different charges, it is our hope that your child will be progressing with
each visit to our office. This means that, each time your child receives therapy, we will be
adjusting their treatment to follow their development.

Please check each box and sign the bottom.

I understand that I am responsible for bringing in all checks sent to me by my insurance
company for services rendered.
I understand that I will be financially responsible if I deposit or cash checks meant for services
rendered to Leaps and Bounds, PT.
If I fail to bring in any checks owed to Leaps and Bounds, PT, I agree to be charged the
amount owed on my credit card on file.
I recognize that policies are subject to change at the discretion of Leaps and Bounds, PT.

I have read and agree to all the above policies.

Parent/Guardian’s signature: ___________________________________ Date: __________________

 Page 1 of 2
Leaps and Bounds, PT

STATEMENT OF PRIVACY NOTICE

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION.

• We may disclose your child’s healthcare information to other healthcare professionals

within our practice for the purpose of treatment, payment, or healthcare operations.
• We may disclose your child’s healthcare information to your insurance provider for the
purpose of payment or healthcare operations.
• We may disclose your child’s healthcare information to notify or assist in notifying a
family member or another person responsible for your child’s care about their medical
condition or in the event of an emergency or of your child’s death.
• As required by law, we may disclose your child’s health information to public health
authorities for purposes related to: preventing or controlling disease, injury or disability,
reporting child abuse or neglect, reporting domestic violence, reporting to the FDA
problems with products and reactions to medications, and reporting disease or infection
exposure.
• We may disclose your child’s health information in the course of any administrative or
judicial proceeding.
• We may disclose your child’s health information to a law enforcement official for purposes
such as identifying and locating a suspect, fugitive, material witness or missing person,
complying with a court order or subpoena, and other law enforcement purposes.
• We may disclose your child’s health information to coroners or medical examiners.
• We may disclose your child’s health information to organizations involved in procuring,
banking, or transplanting organs and tissues.
• We may disclose your child’s health information to researchers that have been approved
by an Institutional Review Board.
• It may be necessary to disclose your child’s health information to appropriate persons in
order to prevent or lessen a serious and imminent threat to the health or safety of a
particular person or to the general public.
• We may disclose your child’s health information for military, national security, prisoner
and government benefits purposes.
• We may leave a message on an answering machine or with a person answering your phone
for the purpose of scheduling appointments. No personal health information will be left
during this message.
• You have the right to request restrictions on certain uses and disclosure of your child’s
health information. Please be advised, however, that we are not required to agree to the
restriction you have requested.
• You have the right to have your child’s health information received or communicated
through an alternative method or sent to an alternative location other than the usual
method of communication or delivery, upon your request.
• You have the right to inspect and copy your child’s health information.

Patient’s Name: _________________________________

Continued on next page
 Page 2 of 2

• You have a right to request that we amend your child’s protected health information.
However, we are not required to agree to amend it.
• You have a right to receive an accounting of disclosures of your child’s protected health
information made by us.
• You have a right to a paper copy of this Notice at any time upon request.

We reserve the right to amend this Notice at any time in the future. Until such amendment is
made, we are required by law to comply with the Notice. If you have any questions about this
Notice, or want more information about your child’s privacy rights, please contact us at (718) 477-
1911.

If you are not satisfied with the manner in which this office handles your child’s privacy, you
may submit a formal complaint to:
DHHS, Office of Civil Rights
200 Independence Avenue SW
Room 509F HHH Building
Washington, DC 20201

I have read this Notice and understand my child’s rights as contained within.

By way of my signature, I provide Leaps and Bounds, PT with my authorization and

consent to use and disclose my child’s protected healthcare information for the purposes
of treatment, payment and healthcare operations as described in this Notice.

Patient’s Name: ____________________________________________________

Parent/Guardian’s Signature: ________________________________________ Date: ___________

Office Staff Signature: ______________________________________________ Date: ____________

 IN MOTION PT, PLLC D/B/A LEAPS AND BOUNDS, PT
PARENTAL RELEASE AND CONSENT

I, the undersigned, being the parent or legal guardian of the unemancipated minor set
below (the “Minor”), and acting for and on the Minor’s behalf, do hereby release, consent, and
grant the following rights and permissions (this “Release and Consent”) to In Motion PT, PLLC
d/b/a Leaps and Bounds, PT (“Leaps and Bounds”), together with its officers, directors,
employees, legal representatives, agents, affiliates, and assigns, those for whom Leaps and Bounds
is acting, and those acting with their authority and permission (collectively, the “Authorized
Persons”).

The Authorized Persons may record the Minor’s image, voice, or likeness in photographs,
videotapes, digital recordings and/or other records or materials (the “Recorded Likeness”) and
may publish, license, and use such Recorded Likeness, with or without the inclusion of Minor’s
name, in connection with advertising and promoting the business of Leaps and Bounds
(“Promotional Materials”). The use of the Recorded Likeness in the Promotional Materials is
without restriction of any media posts (i.e., Twitter, Facebook, Instagram and similar services),
print advertising and other promotional materials in any and all manner of media worldwide. I
agree that the Recorded Likeness may be altered or edited and that neither I, nor the Minor, shall
have any ownership or any other interest in the Recorded Likeness, nor shall either of us be
entitled to receive any royalty or other compensation for the use of the Recorded Likeness, or
have any right to inspect or approve any use of the Recorded Likeness, including any text or other
materials which may accompany the Recorded Likeness.

Each of the Authorized Persons is hereby released, discharged, and shall be held harmless
from and against any liability in connection with the making and use of the Recorded Likeness as
permitted herein, including, but not limited to, any claims or liability based upon or relating to
any right to privacy, publicity, and/or confidentiality, and any claims or defamation and/or
copyright infringement. Without limiting the breadth of the foregoing, this Release and Consent
shall be interpreted to satisfy the requirements of section 50 of the New York City Rights Law.

I hereby represent and warrant that I am a parent or legally appointed guardian of the
Minor and that I have the right to enter into this Release and Consent for and on behalf of myself
and the Minor.

Parent/Guardian’s Name (print): _________________________________

Address: ______________________________________________________
Minor’s Name: _________________________________________________
Minor’s Date of Birth: ___________________________________________

Parent/Guardian’s Signature: _____________________________________ Date: ______________