Policies for Easter Seals South Carolina Therapy Services

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1 Policies for Easter Seals South Carolina Therapy Services It is our goal to serve you and your child with excellence. Please carefully read through the following policies. 1. During or prior to your initial session, you will be asked to complete an authorization form for assignment of benefits, rendering of therapy services, and release of medical records. 2. If you have private insurance, Easter Seals South Carolina will file with them prior to billing Medicaid or BabyNet. 3. Easter Seals South Carolina will file with SC Medicaid and BabyNet. Payment received from these entities will be viewed as payment in full. 4. It is your responsibility to notify us of any changes in your child s insurance coverage, to include status and policy number. 5. It is your responsibility to notify us of any changes in the primary care physician, address, phone numbers, and primary caregiver. 6. If a child is seen in the daycare setting, the therapist will leave a copy of the daily note for you to get when you pick up your child. It is your responsibility to inform the therapist when your child will not be at daycare for therapy. 7. Easter Seals South Carolina has the right to discontinue services if you do not comply with the attendance policy. If a parent needs to cancel therapy, parents are requested to contact the therapist with as much notice as possible. Please be mindful that many of our therapists drive a great distance to reach a patient s home. We ask that you be respectful of their time by giving them notice if you will not be home or if your child is sick. 8. If your child has a fever within 24 hours of a treatment session, please contact your therapist. We work with medically fragile children and are mindful of minimizing the exposure to potentially dangerous illnesses. 9. All questions and concerns regarding billing should be directed to Melissa Griffin or Shae Peak The patient has the right to: Patient Rights Be treated with dignity and privacy; and receive appropriate, considerate, and respectful care. Refuse Treatment Receive information necessary to give informed consent prior to the start of treatment Received a timely response to a request of service Treatment by qualified personnel with appropriate level of experience Be given notice of anticipated termination of services or transfer of therapist Be fully informed of the policies of Easter Seals South Carolina therapy services HIPAA Notice of Privacy Practices: This notice describes how health information about you may be used and disclosed and how you can access this information. This notice is posted on our web site for you to read at If you have any questions, please call The policies contained herein regarding Easter Seals South Carolina therapy services have been explained to me, and I agree to them. I have been informed of my rights as a patient of Easter Seals South Carolina and understand the HIPAA Notice of Privacy Practices. Print Child s Name Parent/Guardian Signature Therapist Signature

2 Today s : Easter Seals South Carolina Therapy Registration Form Patient Information Name: Male Female of Birth: Social Security #: Street Address: PO Box: City, State, Zip Code: Home Phone: Work/Cell: Parent/Guardian Name: Relationship: Referring/Primary Care Physician Physician s Name: Practice Name: Practice Address: Practice Phone: Practice Fax: Insurance Information Medicaid Number: BabyNet Client: Yes No Early Interventionist/Service Coordinator: Phone: Primary Insurance Company: (please include copy of card if possible) Cardholder s Name: Policy Number: Secondary Insurance (if applicable): Health and Developmental History Medical Diagnosis/Reason for Referral: Was your child: Full Term Premature If preterm, how many weeks gestation? Were there any complications at birth? If yes, please describe: List any medications your child is currently take: Does your child have allergies: Yes No If yes, what is the allergy? Significant Medical History: At what age did your child: Sit Alone Crawl Walk Stand Dress Self Feed Self Use Words Please list any concerns that you have regarding your child s behavior or development: Has your child ever received therapy services? Yes No If so, what type? OT PT ST Where did your child receive therapy services? When was your child last evaluated? Parent/Guardian Signature

3 HIPAA AUTHORIZATION FORM Authorization for Use or Disclosure of Information for Purposes Requested by Easter Seals South Carolina Pediatric Therapy Services I,, hereby authorize Easter Seals South Carolina Pediatric Therapy Services to: Use the following protected health information and/or Disclose the following protected health information to: Schools Early Intervention Pediatricians Other Specifically described the information to be used or disclosed including but not limited to, meaningful descriptors such as date of service, type of services provided, level of detail to be released. This protected health information is being used or disclosed for the following purposes: Treatment Research Payment of Services Other This authorization shall be in force and effect until one calendar year following patient's discharge from therapy services at Easter Seals South Carolina at which time this authorization to sue or disclose this protected information expires. I understand that I have the right to revoke this authorization in writing at any time by sending such written notification to Easter Seals South Carolina PO Box 5715 Columbia, SC I understand that information used or disclosed pursuant to this authorization may be subject to disclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to: ( ) Inspect or copy the protected health information to be used or disclosed as permitted under federal or state law to the extent the state law provides greater access rights. ( ) Refuse to sign this authorization The use or disclosure requested under this authorization will result in direct or indirect remuneration to Easter Seals South Carolina Pediatric Therapy Services. Signature of Parent/Guardian Printed Name of Parent/Guardian Printed Name of Child

4 Consent for Treatment I, undersigned, do hereby agree and give my consent for Easter Seals South Carolina to furnish physical, occupational, and/or speech therapy services to, in order to diagnose and treat his/her developmental concerns. Medicaid/Related Programs and Private Insurance & Third Party Benefit Assignment Consent to Treat/Release Information I hereby assign all medical benefits to include major medical benefits to which I am entitled, including Medicaid, private insurance, and third party payers to Easter Seals South Carolina. A photocopy of this assignment is to be considered as valid as the original. I hereby authorize said assignee to release all information necessary, including medical records, to secure payment. I authorize and request that payment of Medicaid or other private insurance/third party insurance benefits be made on my behalf to Easter Seals South Carolina for any services provided to my child. I understand that for any period of time when my child is eligible for Medicaid or its related programs, Easter Seals South Carolina may bill for those services provided and be paid directly by the Medicaid program. Easter Seals South Carolina has permission to bill Medicaid retroactively for services performed prior to the date of this consent. By signing this form, I also give Easter Seals South Carolina permission to release or exchange medical or other confidential information as needed for treatment, payment, determination of benefits, processing of claims, and/or auditing of Medicaid benefits for those services. I acknowledge that I am responsible for notifying Easter Seals South Carolina of any changes in my child s insurance coverage. Child's Name Child's DOB Parent/Guardian Signature

5 ATTENDANCE POLICY To ensure each patient gets the most benefit out of his/her therapy, consistency in attendance is very important. All patients will be expected to attend all scheduled appointments, and cancel any scheduled appointments as far in advance as possible, when needed. If the patient arrives more than 15 minutes past the scheduled time, the therapist may not be able to treat that day, and the appointment would need to be rescheduled. Late arrivals where the patient is unable to be seen will be counted as no shows. Loss of a set appointment time or discharge may occur under any of the following situations: Attendance is less than 75% The patient is consistently late for scheduled appointments Two consecutive appointments are missed Three or more appointments are cancelled in a month's time It does become necessary from time to time to cancel your appointment due to therapist illness or absence. In these instances, the cancelled appointments will not be counted against the patient. Patients seen on a follow-up basis (less than 2 times per month) will be discharged if the patient misses more than one appointment or no contact is received from patient within one month of missed appointment. Patient/Guardian Therapist

6 Media Consent and Release Updated 3/2/15 Child s Name: DOB: Parent s Name: I hereby consent to the participation of my child/family in the media types activities listed below. My initials below indicate which media Easter Seals of South Carolina is allowed to use personal interviews, quotes, photographs, movies or video tapes. Facebook, Twitter, Instagram, and other social media sites Easter Seals of South Carolina website Easter Seals Public Awareness Materials (flyers, brochures, folders, etc.) Easter Seals National Media I also grant to the right to edit, use, and reuse said products for nonprofit purposes including use in print, on the internet, and all other forms of media. I also hereby release Easter Seals of South Carolina and its employees from all claims, demands, and liabilities whatsoever in connection with the above. I understand that this authorization may be revoked by me at any time when action has already been taken. I further understand that this revocation must be in writing and specify the date of revocation. Parent/Guardian Signature: Witness: : :

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