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New Patient Portal

Please find the new patient forms below. Kindly complete forms A-C provided. If you encounter any issues with the form below, you may download the PDF version and return the completed document to info@connectiontherapyclinic.com.

FORM A

Demographic Information

Contact Consent

I understand that I will be receiving my child's evaluation report, progress report and other information regarding their care from Connection Therapy Clinic via e-mail. The e-mail address listed below is to be used.

Medical Information

Education History

Development History

Pregnancy and Birth

Delivery

Development Milestones

Feeding & Oral Motor

Does your child demonstrate any of the following difficulties with feeding or oral motor skills?

Fine Motor & Sensory Processing

Gross Motor Planning

Speech and Language

I acknowledge the information that has been reported in this document is true and correct. I understand that failure to report comprehensive information regarding my child’s medical condition(s), diagnoses, and/or developmental history may compromise their ability to receive the appropriate therapeutic services. As a private business, Connection Therapy Clinic reserves the right to refuse service at any time.

FORM B

Participation Release

I, the undersigned parent(s) of                                                                           , a minor, understand that participation in speech/language therapy, occupational therapy, and/or social group therapy may involve the use of suspended equipment, climbing equipment, and/or various other active play equipment. I understand this is an integral part of my child's therapeutic process.

 

In addition, I the undersigned parent(s) of                                                                          , a minor, do hereby release, discharge and hold harmless the staff at Connection Therapy Clinic and Connection Therapy Clinic, Inc. from any and all claims and/or liability for personal injury, property damage, and claims of any nature or type arising out of my child’s attendance at and participation in any therapy session.

 

This release is and shall be binding upon my heirs, assigns, executors, and administrators.

Physician Information

Other Specialists:

Emergency Contact & Medical Information

Media Release

I, the undersigned, do hereby grant or deny permission to Connection Therapy Clinic to use the image of my child,                                                                               , as marked by my selection(s) below. Such use includes the display, distribution,

publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that

include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as

those on the Connection Therapy Clinic Social Media.

 

Grant permission to use my child’s image in the following ways:

Mark all that apply

Healthcare Eligability Waiver

The Patient or Patient’s Legal Representative herby certifies that they are have chosen Connection Therapy Clinic as the provider of their health care. Furthermore, the Patient or Patient’s Legal Representative understands that they are financially responsible for all costs incurred during the delivery of health services, and agrees to pay these charges to Connection Therapy Clinic accordingly. Lastly, The patient or patient’s legal representative understands that they are also financially responsible for the cost of all non- covered, unauthorized, or services deemed to be “not medically necessary” by their insurance company. In the event your insurance chooses not to reimburse for any or all rendered services provided by Connection Therapy Clinic, you are ultimately responsible for all charges.

I have been notified of the therapy benefit information provided by my insurance company. I have also been advised to contact my insurance company regarding any therapy limits and exclusions specific to my policy.

Insurance Information

The main payment method at Connection Therapy Clinic is currently through private pay. We are continuously striving to expand our network of insurance partners in order to enhance our services for families. Presently, we exclusively accept insurance providers from Anthem Blue Cross and Aetna. If you wish to share your insurance details, we will gladly keep them on record as we pursue becoming approved in-network providers.

Upload front & back of insurance card

Consent and Releases

FORM C

Acknowledgment of Privacy Practices

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information (PHI). I understand this information can and will be used to: (1) conduct, plan and direct my treatment and follow-up among the multiple health care providers who may be involved in that treatment directly and indirectly, (2) Obtain payment for services, and (3) conduct normal health care operations. I have received, read and understand the “Notice of Privacy Practices” containing a more complete description of the uses and disclosure of my health information. I understand that Connection Therapy Clinic has the right to change its “Notice of Privacy Practices” from time to time and that I may contact Connection Therapy Clinic at (949) 385-1410 at any time to obtain a current copy. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations.

Consent for Bathroom

I hereby authorize Connection Therapy Clinic to allow my child to use the bathroom with staff assistance and supervision. If my child is not toilet trained, I authorize Connection Therapy Clinic staff to provide diaper changing if required during the therapy session.

Choose one

Financial Responsibility & Insurance Billing

Payment & Insurance Information

We accept checks, cash, debit cards, and credit cards. At this time, we only accept payment through Anthem & Aetna, no other insurance or managed care companies. We do provide receipts which you can submit to your insurance company for possible reimbursement for out-of-network, outpatient occupational therapy and speech therapy. Insurance may require a doctor referral with diagnosis(es). Please contact your insurance company with further questions regarding reimbursement rates. Payment in full is required at the time of service .

Connection Therapy Clinic does not directly work with insurance companies for coverage of services and is not a “preferred provider” for any insurance company outside of Anthem & Aetna. However, we will provide receipts with ICD diagnostic codes and CPT procedure codes so that you can submit the receipts to your insurance for possible reimbursement. For insurance reimbursement, you will need to obtain a referral from your child’s physician. The referral should include “occupational therapy” or "speech therapy", the diagnosis with ICD code number, that the physician will review progress at regular intervals (e.g. every 6 months), and the frequency of intervention (e.g. 45 min, weekly/ 30 min twice a week). A sample physician referral for your doctor to use as a guide can be provided upon request. If your insurance company ever questions and wants documentation for the “medical necessity” for the therapy, they want documentation from a physician. A sample of this medical necessity documentation can be provided for your doctor.

Policies

Packaged Sessions Make-up Policy

You are able to schedule make-up sessions up to seven days in advance. Make-up sessions do not expire as long as your are currently receiving treatment, however, if a make-up session is missed or cancelled for any reason, it is no longer eligible for rescheduling. Make-up sessions are also not able to be used toward monthly packages.

Payment Failure

In the event that you make payment with a check which is returned by the bank without payment, you will have 7 days from the time you are notified to make alternate payment arrangements. You will be responsible for any bank fees or charges because of the returned check. In the event that a second check is returned for non-payment, bank fees plus a $25 bookkeeping and processing fee will be charged. Any balance past due by more than 30 days shall be subject to interest charges of 1.5% per month, plus a $25 bookkeeping and processing fee per month.

Reimbursement/Funding of Services

Services provided are occupational therapy, speech therapy, and group classes. For some children, services may or may not be considered “educationally necessary” or “medically necessary”. Our assessment of needs and recommendations will be done in an independent manner and will not attempt to answer funding or reimbursement issues.

No Shows

Appointments are a contract for the exclusive use of the therapist’s time. Parents will be charged the full session rate for no-shows. Please call to cancel if you are unable to make an appointment. Receipts for payments received due to a no-show or failed appointment will reflect no services given and are not eligible for reimbursement by your health insurance.

Cancellations

A limited number of advanced notice cancellations (more than 24 hours notice) for any reason, are provided without incurring a charge. The following are offered each season:

  • 2 sessions during the Winter/Spring (beginning of January to mid-June)

  • 2 sessions for the Summer schedule (mid-June to mid/late August)

  • 2 sessions during Fall (mid/late August to end of the year)

For a child attending therapy twice weekly, 3 cancellations are allowed for each season. Cancellations beyond these numbers (excess cancellations), with more than 24 hours notice, will be charged at 1/2 the regular therapy rate.

Cancelation Due to Illness

Cancellation due to illness with less than 24 hours notice, but prior to the scheduled therapy time will be charged at half the therapy rate. Please cancel if your child has had, within 24 hours of the therapy appointment, a fever, vomiting, diarrhea, pink eye, or any other contagious condition. We do not want to expose others to illness. If your child has some congestion (without discharge) and only slightly reduced energy, the therapist can generally work on less physically demanding tasks

for that session.

Notice to Discontinue/Change Therapy Times

If you choose to discontinue therapy or decide to change the scheduled therapy time, you will need to provide 2 weeks notice prior to your last session. This means that your therapist will provide 2 more sessions following the date of notification, unless you are seen more than one time per week, it which case the number of sessions will equal the 2 weeks, multiplied by the number of times you regularly receive therapy per week.

Late Returns

While we realize there are times a parent or caregiver may need to leave the clinic during the therapy session, we cannot have staff available and be responsible for monitoring/supervising the child once the therapy session is over. Therapy sessions are 30 or 45 minutes in length. Additional time will be charged at the regular therapy rate for late pick-up of a child.

Right to Refuse/Discontinue Service

Our interpretation, recommendations and treatment plans are based, in part, on the history and information that you provide us. If information about your child’s medical/educational history, interventions and needs are withheld, misrepresented, altered or omitted, we reserve the right to terminate the services. Services may be refused or discontinued due to non-payment of services, lack of cooperation, or a poor match between the needs of the family and skills of the therapist.

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