MY RECESS THERAPY PARENT FORM LIST

Transcription

1 MY RECESS THERAPY PARENT FORM LIST AUTHORIZATION OF RELEASE OF INFORMATION VIDEO AND PHOTO RELEASE PRIVATE PAY THERAPY SERVICES PHYSICIANS ORDER FOR THERAPY SERVICES SICK POLICY & HYGIENE THERAPY SERVICES AGREEMENT Please complete the following forms electronically or print legibly. Save, print and sign all forms to bring with you to your first appointment at My Recess Therapy. You may also print, sign, and fax these forms prior to your visit at All forms must be completed and signed before initial consultation or visit is scheduled. My Recess Therapy does not guarantee coverage by your insurance and requires a 50% payment of services until insurance has verified payment. My Recess Therapy will refund any money charged once the insurance company has paid within 30 days of receipt of insurance payment. Intake Form List 1

2 AUTHORIZATION OF RELEASE OF INFORMATION I,legal guardian for authorize permission for My Recess Therapy, Inc to exchange information with: Name Discipline/Relationship Address/Phone Information to be released: Parent Signature: Witness: Information Release 2

3 VIDEO AND PHOTO RELEASE This signed paper indicates that I am in agreement to have my son/daughter video-taped and/or photographed. I give my permission for these videos or photos to be viewed by others as an educational tool. Child s Name: Guardian s Signature: OPTIONAL: I further agree to have my son/daughter s photographs to be displayed on my therapists website, social media (pictures, videos, and treatment progress), or used in publications related to My Recess Therapy, Inc in order to share my child s accomplishments and demonstrate the work done at their clinic as indicated by my signature below. Guardian s Signature: Video and Photo Release 3

4 PRIVATE PAY THERAPY SERVICES FEE SCHEDULE AND PAYMENT POLICY If therapy is not being billed to your insurance company or if payment is pending insurance consent, payment is required at the time of service. The following is the current fee schedule and financial policy for private pay services provided by My Recess Therapy, Inc. My Recess Therapy reserves the right to change or modify the fee schedule listed below at any time. You will be notified 30 days in advance of prior to fee changes. All fees and costs are due at the time of service. We accept debit/credit cards or personal check. An itemized statement will be provided to you for therapy sessions (upon request only) and can be used to submit to your insurance for reimbursement. Reimbursement from your insurance is not guaranteed by My Recess Therapy. FEE SCHEDULE OCCUPATIONAL THERAPY SPEECH THERAPY EVALUATION $ $ Evaluations are billed at a set rate, fees include test administration and scoring, evaluation write-up, and parent discussion/development of therapy goals and treatment plan. TREATMENT SESSION $ per hour $95.00 per session This fee includes a full treatment session, parent education, and home programs. FAMILY AND CHILD CONSULTATION $ per hour $95.00 per session Includes parent meeting SCHOOL OBSERVATION AND CONSULT $ per hour $95.00 per session This fee includes phone or personal consultations with service providers, teachers, daycare workers, school or community observations and treatment, peer facilitation activities REPORT WRITING $ per hour $ per hour Hourly rate for any report writing above and beyond what is typical in a treatment session. This charge is not covered by insurance. TRAVEL Up to $25.00 Up to $25.00 This fee is for your therapists travel distance and time and at the discretion of your therapist. Please sign to show your agreement to the charges above. Additional fees will be discussed with the family prior to applying to your bill. Guardian s Signature: Private Pay Fee Schedule 4

5 PHYSICIANS ORDER FOR THERAPY SERVICES Client Name: Address: City/State/Zip: Phone: Date of Birth: Parent: therapy evaluation and treatment as needed. This order will be valid one year from the physicians signature date. Office Use Only: TO PHYSICIANS NAME: Address: City/State/Zip: Phone: Fax: PHYSICIAN: PLEASE COMPLETE BELOW ITEMS Medical Diagnosis and/or Description of Disability: Therapy Diagnosis: Current Medication Precautions or Contraindications: Adaptive Equipment: Additional Comments: The following service is prescribed and considered medically necessary: Therapy evaluation and follow up treatment if determined appropriate at the time of evaluation. Frequency and duration to be determined based on plan of care by treating therapist. Physician s Signature: Physician s Phone: Fax: ** Please fax signed copy to My Recess Therapy, (fax). Physicians Order 5

6 SICK POLICY My Recess Therapy is a multi-disciplinary pediatric therapy clinic. Due to the medical needs of our clients and in consideration of health of our staff/therapist, we require that parents/caregivers cancel treatment sessions for the following reasons: Illness symptoms within the last 24 hours Fever: temperature of 100 F or 38 C or greater within the last 24 hours Diarrhea: Five or more loose, watery stools within 24 hours Vomiting within the last 24 hours Sore throat or difficulty swallowing Rash or spots on skin; ringworm infection Severe itching Mouth sores Eye discharge Unusual nasal discharge Uncontrolled coughing Difficulty breathing, wheezing Wounds that are not properly covered HYGIENE SOILED CLOTHING If you child has child has urinated or defecated in their clothing during a treatment session and does not have a proper change of clothes, the session will be ended at that time. HEAD LICE My Recess Therapy supports the Head Lice Policy of the American Association of Pediatrics. If you know your child has live crawling head lice, begin a treatment to kill live lice before coming to therapy. We advise seeking professional care of lice and nit removal. Child must be cleared of nits and lice prior to returning to therapy clinic to support containment of lice and reduce risk of spreading to other and on therapy equipment. Please sign to acknowledge and accept the terms of the above sick and hygiene policy. Parent s Signature: Sick & Lice Policy 6

7 Reviewed By: 1601 E Main Street, Unit G Saint Charles Il, Phone: Fax: info@myrecess.com THERAPY SERVICES AGREEMENT SECTION ONE: Terms of Service My Recess, Inc. strives to provide quality treatment services for your child. Regular attendance is necessary to establish a positive treatment routine and to ensure progress is made toward your child s goals. We want your family to view your child s treatment appointment as a regularly scheduled event. In fairness to children currently waiting for services, please be advised of our attendance policy. CANCELLATIONS FEES / ACTIONS A 24 hour notice is required No Fee for a cancellation* A cancellation less than the $35.00 required 24 hour notice 3 cancellations in a row Placed on waiting list, lose regularly scheduled appointment time Holiday late cancellation $60.00 NO SHOW FEES / ACTIONS No show appointment $ no show appointments in 1 month Placed on waiting list 3 no show appointments Discharged Holiday* no show appointments $75.00 We understand that extenuating circumstances may occur and will be placed under consideration with your therapy team and the My Recess Therapy administration. Implementation of any fee or action is at the discretion of your therapist. Thank you for allowing My Recess Therapy to service your the treatment needs of your child. By signing below, I the parent/guardian of therapy services agreement. agree to the above stated Parent or Legal Guardian s Signature: * Cancellation or no show appointments related to Holiday weeks or inclement weather are subject to the discretion of your therapist. If weather conditions prevent you from traveling to our offices, please notify your therapist within the required 24 hour period or as soon as possible in order to avoid cancellation or no show fees. Holiday weeks are the weeks preceding or following any national holiday. National holidays are holidays recognized by the government. Therapy Services Agreement 7

8 Reviewed By: THERAPY SECTION TWO: Communication and Correspondence Please check which methods of communication are acceptable for discussing treatment appointments as Cell Phone Text Message Home Phone I agree to receive communication from My Recess Therapy through the above methods. I understand I am responsible for additional data charges imposed by my service provider and acknowledge My Recess Therapy is not liable for any compromised privacy by my provider/host, Internet service, cell-phone or data service. Parent or Legal Guardian s Signature: Therapy Services Agreement 8

9 Reviewed By: THERAPY SECTION THREE: Financial Responsibility Policy I understand that although my insurance may cover a portion of the cost of the therapy services I receive at My Recess Therapy, Inc., I am ultimately responsible for the complete payment of all charges. Payment in full is required for all services at the time they are rendered unless My Recess Therapy is billing my pre-verified insurance. If My Recess Therapy is billing my insurance I will pay any unmet deductible, non-covered services, co-insurance, or co-payments at the time of service. PAYMENTS PENDING INSURANCE CONSENT I understand that my private insurance may not fully cover the services my child receives. In this case, I am responsible for the all services charged at the private pay rate**. Although My Recess Therapy takes every attempt to prevent this, I understand I may be charged 50% of the fee until insurance has verified payment. My Recess Therapy will refund any money charged once my insurance has paid within 30 days of receipt of insurance payment. INSUFFICIENT FUNDS I understand that if my account is past due 30 days, My Recess Therapy will bill the credit card below to cover my outstanding balance and a $20.00 service fee will be charged to me on all checks returned for non- sufficient funds. In the event my account is turned over to a collection agency, a collection fee of 25% of the outstanding balance will be added to my account to cover the cost of collection. All clients must fill-out the credit card information. If you would also like to bill this credit card automatically at the time of service from your unmet deductible, non-covered services, co-insurance, or co-payments, please check the box, sign, and date. Private pay clients must choose YES. My Recess Therapy accepts payment in the form of cash, check, or credit card. Yes, please bill my credit card automatically at the time of rendered services. No, I would prefer a bill be sent to my home monthly. The credit card form must be completed by all clients regardless of billing cycle status. Credit card information is required for services rendered and pending insurance consent and for other services and fees charged without a valid or timely payment by the client. *Required CARD TYPE* Visa Mastercard Discover Flex Spending Card Number*: Name on Card*: Expiration Date*: Verification Code*: Authorized Signature: I understand and agree to the terms of the financial responsibility policy. Client Name: Signature: **See Private Pay Therapy Services Fee Schedule and Payment Policies. Physicians Order for Therapy Services 9