TW2 - Policies & Financial

TW2 Policies & Financial Forms
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Child's Name*

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Parent/Caregiver completing this form:*

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Name of Primary Contact*

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Email*
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Cell Phone Number*
Address*

Street Address

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Name of Secondary Contact

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Welcome to Therapy West 2. We appreciate the opportunity to work with you and your child. The following policies have been designed to help guide you through the procedures at Therapy West 2.

THERAPY AGREEMENT & CONSENT

Your signature below forms a binding agreement between Therapy West 2 and the Responsible Party for minor patients. Responsible Party is the individual who is financially responsible for payment of services.

All charges for services rendered are due and payable at the time of service. Invoices are available upon request.

All invoices related to comprehensive and cosultative evaluations must be resolved and payments made before the full evaluation report is released.
Name of Responsible Party*

First NameLast Name
FEE SCHEDULE

Comprehensive Evaluation $450

-Full evaluation with standardized testing of multiple developmental areas. A written report will be provided to parents as well a 15 minute meeting with the therapist to discuss the results. If treatment is warranted, a plan of care and goals will be created upon initiation of treatment. Approximate lenght of time is 1.5 hours.

Consultation   $275

-Consultation with standardized testing and clinical observations will be conducted and written report will be provided to parents as well a 15 minute meeting with the therapist to discuss the results. If treatment is warranted, a plan of care and goals will be created upon initiation of treatment. Consultations are only available for concerns related to articulation, fine motor/handwriting, social skills and specific executive function. Approximate length of time is 1 hour.



Re-Evaluation $175

-Required re-evaluation every 6-9 months or at time of discharge to measure progress.

OT/ST Individual Treatment   $140/hour

-Sessions are 50 minutes in length including time to discussion with parent. If appropriate, sessions can be pro-rated for shorter duration.

Tutoring (Elementary) $75/hour

Tutoring (Middle School) $80/hour

Tutoring (High School Grades) $80/hour

-Reading, writing and math

You will be billed for all services at the end of each day. Your insurance will not be billed. It is your responsibility to file a claim with your insurance company. Payment must be made within 10 days in order to continue treatment.

If a payment is made on an account by check and the check is returned as Non-Sufficient (NSF), Account Closed (AC), Refer to Maker (RTM) or a Stopped Payment, the Responsible Party will be responsible for the original check amount in addition to a $35.00 Service Charge. Once notice is received of the returned check, Therapy West 2 will notify the Responsible Party of the returned check. If a response is not made within 15 days from the letter date by the patient or the Responsible Party, the account may be turned over to our collection agency and a collection fee will be added to the outstanding balance – in addition to the $35.00 Check Service Charge.

Should collection proceedings or other legal action become necessary to collect an overdue account, the patient or the patient’s Responsible Party, understands that Therapy West 2 has the right to disclose to an outside collection agency all relevant personal and account information necessary to collect payment for services rendered. The patient, or the patients Responsible Party understands that they are responsible for all cost of collection including, but not limited to: interest due at 18% APR, all court costs and Attorney fees and a collections fee will be added to the outstanding balance.
I consent to the following services for my child: (please mark all that apply)*

OT EvaluationOT Treatment (Requires having a recent OT evaluation)SLP EvaluationSLP Treatment (Requires having a recent ST evaluation)TutoringGroupsOther
Type of evaluation/treatment you are scheduling: (N/A if already have evaluation and are seeking treatment). If unsure, this can be discussed prior to evaluation.*

OT Comprehensive EvaluationOT Consultative Evaluation (Note: if sensory processing is a concern, this would be a comprehensive evaluation)SLP Comprehensive EvaluationSLP Consultative Evaluation (for concerns like articulation)Speech Therapy Treatment Only (Please Provide previous ST evaluation)Occupational Therapy Treatment Only (Please Provide previous OT evaluation)Not sure, would like to discuss prior to evaluationOther
I do hereby consent to an OT or ST evaluation (please initial)*
If warranted, I do hereby consent to occupational or speech therapy treatment (please initial)*
By signing below, you agree to accept full financial responsibility as a patient who is receiving medical services. Your signature verifies that you have read the above disclosure statement, understand your responsibilities and agree to these terms.
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THERAPY ATTENDANCE POLICY

Attending 80% of therapy appointment is mandatory. Attendance rates below 80% or not calling to cancel a scheduled appointment may result in removal from the schedule.

If your child is ill, please call to cancel your appointment. If your child has a prolonged illness (2 consecutive cancellations due to illness) or contagious illness, you must bring a medical clearance from your doctor in order to resume therapy.

To cancel an appointment, please notify your therapist or leave a message at (407) 900-3026. When leaving a message, please include the time of appointment being canceled, the therapist(s) name and the available days and times the session can be made up.

Make up sessions are not guaranteed and are subject to time and therapist availability.

If you have questions or require more time to talk with your therapist, please make an appointment to talk later by telephone. Consultations (in person or on the phone) that exceed 10 minutes will be charged in 15 minutes increments at the rate of a private therapy session.

It is mandatory that your child be picked up on time after their session. A $20.00 per 15 minutes or fraction thereof will be charged to the parent and must be paid at the time of pick up.

If you are leaving the premises during your child’s therapy time, please make sure that your therapist has a means of contacting you.

Therapy sessions are often video taped by your treating therapist (especially if your child is under 1 year of age) for record keeping documenting progress and in order to assist your therapist with future treatment planning. Videos are also used for other educational purposes. Photographs are taken regularly for our TW newsletters or to display on our walls at Therapy West 2. A photo/videotape release form is included in your new client packet for this purpose. It is optional to sign this release and you are free to stipulate the terms for videotaping and photographing your child. You may be asked to provide Therapy West 2 a copy of any home videos that you have of your child between 8-12 months of age (which will be kept confidential). This is helpful in better understanding the early development of your child.
FACILITIES POLICY

Street shoes are not allowed on the therapy mats. Food, drinks, and cell phones are not allowed in treatment areas.

Siblings are NOT allowed in the treatment areas. Parents or other adults are not allowed to supervise any child on any Therapy West equipment. Parents are required to sit in the waiting room or in a “Parent Observation Chair” if observing a session.

If there are other persons or professionals that would like to observe your child’s session, please notify your therapist at least 1 week before. Therapy West 2 welcomes these visitors, but requires that a designated supervisor be present during the observation and that the visit be limited to 20 minutes.
Please sign below indicating that you have read and agree to the policies stated above.*

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VIDEO, PHOTOGRAPHY & SOCIAL MEDIA CONSENT

At Therapy West 2., therapists videotape or photograph children who receive therapy services to help monitor and document a child’s areas of concern, as well as measure their progress. Videotapes and photos are used and reviewed by Therapy West 2 staff and occasionally may be used in research projects focusing on outcome measures.

Therapists are frequently asked to participate in research and teach at professional courses, seminars or workshops nationally and internationally, as well as to write articles or chapters in technical books. We often include videotapes, slides or photos during our presentations. If photos or videos are used for any of the above mentioned purposes, they will not have identifiable information. Parents are always welcome to view their child’s videotape at Therapy West 2.
I give consent for my child to be videotaped and/or photographed. I understand that my child's name and any identifying information will not be used in association with these images.*

YesNo
Therapy West 2 maintains a brochure, website, Facebook page and Instagram page. Please mark your consent for staff and therapists at Therapy West 2 to take photographs and videos of my child for the purpose of posting on these sites. With this consent, I hereby release and discharge Therapy West 2 from any and all claims arising out of use of the photos and videos. This consent can be changed and revoked by parent at any time.
I provide consent for Therapy West 2 to use photographs of my child on Therapy West 2's brochures:*

YesNo
I provide consent for Therapy West 2 to use photographs and videos of my child on Therapy West 2's website:*

YesNo
I provide consent for Therapy West 2 to use photographs and videos of my child on Therapy West 2's Facebook and Instagram pages. I understand that these posts may be accompanied with my child's first name. :*

YesNo
Signature*

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HIPAA PRIVACY NOTICE

NOTICE OF PATIENT INFORMATION PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO INFORMATION. PLEASE REVIEW IT CAREFULLY.

THERAPY WEST 2's LEGAL DUTY

Therapy West 2 is required by law to protect the privacy of your personal health information (PHI), and to provide this notice about the information practices we follow.

USES AND DISCLOSURES OF HEALTH INFORMATION

Therapy West 2 uses your PHI primarily for treatment; obtaining payment for treatment; conducting internal administrative activities and evaluating the quality of care that we provide. For example, Therapy West, Inc. may use your PHI to contact you to provide appointment reminders, or information about treatment alternatives or other health related benefits that could be of interest to you.

Therapy West 2 may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, and for emergencies. We also provide information when required by law.

In any other situation, Therapy West 2's policy is to obtain your written authorization before disclosing your PHI. If you provide us with a written authorization to release your information for any reason, you may alter revoke that authorization to stop future disclosures at any time.

Therapy West 2 may change its policy at any time. When changes are made, a new Notice of Information Practices will be posted in the waiting room and will be provided to you on your next visit. You may also request an updated copy of our Notice of Information Practices at any time.

PATIENT’S INDIVIDUAL RIGHTS

You have the right to review or obtain a copy of your PHI at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances when we have disclosed your PHI for reasons other than treatment, payment or other related administrative purposes.

You may also request in writing that we not use or disclose your PHI for treatment, payment, and administrative purposes except when specifically authorized by you, when required by law, or in emergency circumstances. Therapy West, Inc. will consider all such requests on a case by case basis, but the practice is not legally required to accept them.

CONCERNS AND COMPLAINTS

If you are concerned that Therapy West 2 may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your PHI, please contact our practice manager at the address listed below. You may also send a written complaint to the US Department of Health and Human Services. For further information on Therapy West, Inc.’s health information practices or if you have a complaint, please contact one of the owners.
Please sign below to indicate that you have received this form and reviewed the information provided:*

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In consideration of my participation in the foregoing, the undersigned acknowledge and agree to the following:

I am aware of the risk of myself and my child participating in activities that may cause injury or illness such as, but not limited to Influenza, MRSA, or COVID-19 that may lead to paralysis or death.I agree to not participate in therapy services if any member(s) in our household experiences symptoms that of fever, fatigue, difficulty in breathing, or dry cough or exhibiting any other symptoms relating to COVID-19 or any communicable disease within the last 14 days.I agree to not participate in therapy services if any members(s) in our household traveled by sea or by air within the past 14 days.I agree to notify the Organization if any member(s) in our household are diagnosed or test positive for COVID-19 virus within 14 days of an appointment.
Following the pronouncements above I hereby declare the following:

I am fully and personally responsible for my own and my child's safety and actions, while and during my participation and I recognize that I or my child may be at risk of contracting COVID-19.With full knowledge of the risks involved, I hereby release, waive, discharge the Organization, its owners, officers, independent contractors, affiliates, employees, representatives, successors, and assigns from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me or my child related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19.I agree to indemnify, defend, and hold harmless the Organization from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19.
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TW2 Policies & Financial Forms