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 firstname.lastname@example.org.
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.
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.
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.
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:
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.
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.
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.
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.
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.
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.