Become a Kool Kid

Step 1

Contact us with your referral.

Kool Kidz accepts referrals from:

Physicians
Early intervention coordinators
Other therapists/educators
From the family itself

Phone: (770) 643-0868
Email: contactus@koolkidzpt.com

Payments Accepted

We accept the following forms of payment:

Private Insurance (out of network provider)
Blue Cross Blue Shield (in network provider)
Private Pay
Medicaid
Peachcare for Kids
Amerigroup CMO
Peach State
CareSource

Step 2

Submit your info.

We need some support information prior to your first appointment. Please fill out the forms.

1Basic Information

2Insurance & Medical History

3Consent & Checklist

Child's Information

Name(Required)

First Last

Date of Birth(Required)

YYYY dash MM dash DD

Gender(Required)

Home Phone(Required)

Address(Required)

Street Address City ZIP Code

Diagnosis(Required)

Child’s School/Daycare

Siblings, Ages

Parent's Information

PARENT 1 (INSURED) Name(Required)

PARENT 1 (INSURED) DOB(Required)

MM slash DD slash YYYY

Cell Phone(Required)

Work Phone(Required)

Email(Required)

Occupation

PARENT 2 Name

PARENT 2 DOB

MM slash DD slash YYYY

Cell Phone

Work Phone

Occupation

Referring Physician

Physician Name(Required)

Phone(Required)

Address(Required)

Insurance Information

Name of Insurance Company(Required)

Phone(Required)

Name of Insured(Required)

Insured Identification #(Required)

Policy #(Required)

Group #(Required)

Is this child covered under another insurance policy?(Required)

Yes

Name of Insurance Company

Phone

Name of Insured

Insured Identification #

Policy #

Group #

Medical History

Date of last Physical/Occupational Therapy Evaluation (may not have had one yet)

MM slash DD slash YYYY

Are your child’s immunizations up to date?

Yes

Does your child have any known allergies?

Yes

If yes, please specify

Was your child born prematurely?(Required)

Yes

If so, at what gestational age was he/she born?

Was your child required to stay in the NICU following birth?

Yes

If so, for what reason(s) and how long?

What would you like your child to accomplish as a result of receiving physical/occupational intervention?(Required)

Is there anything else your therapist should know regarding your child that might assist her in working with you child?

DISCLOSURE AND ACCEPTANCE OF KOOL KIDZ POLICIES

Acting on behalf of the patients, I consent to the necessary care and/or treatment of the patient by the therapists doing business for Kool Kidz, Inc. I consent to care and treatment that falls within the scope of physical/occupational therapy practice as defined by the State of Georgia and the American Physical Therapy Association. I understand that the practice of medicine, including physical/occupational therapy, is not an exact science and that treatment will involve physical participation on the part of the patient which may involve risks of injury. I acknowledge that no guarantee has been made to me as the result of evaluation and/or treatment.(Required)

Consent

I consent to the taking and publishing of still or motion pictures of the patient’s diagnosis and treatment. I further agree that the information from the patient’s medical record may be disclosed for educational and/or research purposes.(Required)

Consent

I understand that the patient’s valuables and personal belongings are my responsibility and that Kool Kidz Inc. shall not be responsible or liable for any loss, theft, misplacement, or damage of personal belongings.(Required)

Consent

I agree that in consideration of the services rendered to the patient, obligate myself to promptly pay the account of Kool Kidz, Inc. in accord with the regular rates and terms of the practice. I understand that physical/occupational therapy services are rendered and charged to the patient and not to the insurance company. Kool Kidz, Inc. cannot accept total responsibility for collection for my claim nor for negotiating a disputed settlement. Please be advised: We bill insurance as a courtesy. I understand verification of benefits is not a guarantee of payment. I am ultimately responsible for all charges if insurance does not cover or pay. I agree to be responsible for all deductibles, coinsurance and non-covered portions of services performed.(Required)

Consent

I hereby authorize medical payment directly to Kool Kidz, Inc. of any health insurance benefits payable to me, including medical insurance, but not to exceed the regular charge for services rendered to the patient.(Required)

Consent

I hereby authorize Kool Kidz, Inc. to release information about this treatment/account to any person or corporation, including but not limited to, insurance carriers, welfare programs, or the patient’s employer as necessary to secure timely payment.(Required)

Consent

I understand I will receive a warning after a 2nd “no-show” appointment (child not available for treatment with any prior notice within 24 hours of appointment). After a 3rd “no show” or repetitive cancellations (without medical documentation), Kool Kidz reserves the right to stop services.(Required)

Consent

I understand Kool Kidz is able to bill my insurance. If my insurance company requires preauthorization, I will go through this process prior to beginning physical therapy.(Required)

Consent

I have read the Kool Kidz Kreed.(Required)

Consent

I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE CONTENTS AND AM COMPETENT TO EXECUTE IT OR IF EXECUTED ON BEHALF OF ANOTHER, I AM AUTHORIZED TO EXECUTE IT ON BEHALF OF THAT PERSON.(Required)

Consent

Name of person authorized to consent(Required)

Date(Required)

MM slash DD slash YYYY

Relationship to patient(Required)

CAPTCHA

CHECKLIST OF ITEMS TO PROVIDE ON YOUR FIRST APPOINTMENT

Prescription from your child’s primary care physician. Documents should specify the number of PT/OT visits recommended each week and should list any precautions. If your child has surgery or any other serious illness while under the treatment of a Kool Kidz therapist, the treating physician must write a resumption prescription for physical/occupational therapy to begin again, listing any precautions.(Required)

Yes

We must have a physical/occupational therapy evaluation on file that is no more than one year old. If your Kool Kidz therapist performed your evaluation, then it will automatically be placed on file. If your PT/OT evaluation was performed outside of Kool Kidz, please provide us with a copy of your child’s chart.(Required)

Yes

IFSP is required if your child is age 0 to 3 and participating in the Georgia Babies Can’t Wait Program. IFSP must reflect Kool Kidz as provider of PT/OT services and accurate number of PT/OT visits per week and length of session.(Required)

Yes

Comments

This field is for validation purposes and should be left unchanged.

Kool Kidz Kreed

Questions? Visit the FAQ page →