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.
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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