The Department of Health and Human Services has established a “Privacy Rule” to help ensure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for health care providers to obtain their patient’s consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations.

As our patient we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your healthcare information and information about treatment, payment or health care operations, in order to provide health care that is in your best interest.

We also want you to know that we support your full access to your personal medical records. We may have to disclose personal health information for purposes of treatment and/or payment.

I agree to discuss my child’s progress during the group held by Summit Pediatric Therapy along with the other participant’s families.  Should I have any additional concerns or questions that I would like to discuss in private with my child’s therapist, I understand I can arrange a separate time to discuss the matter. You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of you PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent.

If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer. You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice.

I consent to receive text messages reminders and phone call reminders from Summit Pediatric Therapy. I understand that this consent to receive email reminders and test message reminders will apply to all future appointment reminders/feedback/practice notifications unless I request that to be changed. You may refuse consent to email or text message reminders at any time.

ALL PAYMENT IS EXPECTED AT THE TIME OF SERVICE.

You are responsible for ensuring all charges are paid whether by you or by your insurance carrier. 

All patients are required to keep a valid credit card on file; expected copayment must be made at the time of service. Summit Pediatric Therapy accepts all major credit cards and debit cards including HSA/FSA cards.   

Accounts with an outstanding balance will be charged to the credit card on file.  If your credit card expires or is declined, you must make arrangements for payment to avoid a break in service, services being discharged, or having your account sent to collections. 

INSURANCE:

Summit will bill participating insurance companies and we will try our best to collect from insurance as a benefit to you.  It is your responsibility to provide us with up-to-date insurance information.  You are expected to pay your portion at the time of service. If we have not received payment from your insurance company within 60-days of the date of service, you will receive a statement and the balance is your responsibility.  If we have not received payment within 90-days, your credit card will be charged at our current private self-rates. 

PRIVATE SELF-PAY: 

If you are electing to be seen as a private self-pay patient, your insurance will not be billed for these sessions.  You are expected to pay the private-pay rate at the time of service.  Private-pay sessions will not be retroactively billed to insurance at a later date; you agree to pay for these services at your own expense. 

If you need assistance or have questions, please contact our billing department Monday through Friday at 720-542-8737 or info@summitpedstherapy.com

Regular attendance is important to achieve progress and success in therapy, and it is necessary that all appointments be kept whenever possible. Failure to keep your scheduled appointments at Summit Pediatric Therapy hinders our ability to provide the best care to our patients. Because of the demand for therapy services and to ensure positive outcomes, we must enforce the following attendance policy.

• We ask that you show us consideration by calling at least 24 hours prior to your appointment if you need to cancel.
• If your child is sick, we ask that you schedule a make-up within 14 days of the cancelled appointment to avoid a late cancel charge of $50
• If you fail to cancel prior to the start of the appointment, this will be counted as a “no show” and you will be assessed a $50 charge for individual therapy or $45 charge for group therapy.
• If you fail to provide notice for any cancellation, you will be charged $50 for individual therapy and $45 for group therapy.
• Patients that arrive more than 10 minutes late for a scheduled appointment will be rescheduled for another day or time.

Repeated late cancellations or no-shows are disruptive to the optimal delivery of care to your child and our other patients. Attendance is reviewed on a monthly basis. As a result, you may be discharged from therapy for the following reasons:

• Three “no shows” in a 90-day period
• Canceling 3 out of 5 appointments in a 60-day period
• Attendance less than 70% of scheduled appointments
• Failure to pay for services rendered

If your therapist is out of the office, we will reschedule your child with another available therapist in order to maintain attendance.

Waiting Room: For the safety of our patients, we require all parents and caregivers to remain in our reception area or outside of the office in the immediate hallway at all times.

I, parent/guardian of child authorize my child to participate in therapies at Summit Pediatric Therapy. I acknowledge the risks and potential for risks of Occupational Therapy, Physical Therapy, and Speech Therapy. However, I feel that the possible benefits to myself / my son / my daughter / my ward are greater than the risks assumed. I hereby, intending to be legally bound, for myself, my heirs and assigns, executors or administrators, waive and release forever all claims for damages against Summit Pediatric Therapy, instructors, therapists, aides, volunteers, and / or employees for any and all personal injuries, physical or mental condition, known or unknown, to said person, and the treatment thereof, as a result of, or in any way growing out of the acts of Summit Pediatric Therapy, its agents, employees, representatives, successors or assigns, including but not limited to their negligence or gross negligence, in rendering the services above described or in any way incidental thereto.

In case of emergency and/or if I am not present and cannot be contacted at the telephone numbers on my child’s parent information form, I understand that in the event of a medical emergency, Summit Pediatric Therapy will call 911 or other appropriate medical personnel. If an ambulance must transport my child, I understand that it will take my child to the closest medical facility available. I give permission to the personnel of Summit Pediatric Therapy to consent to any x-ray examination, anesthesia, medical or surgical treatment and/or other emergency medical care advised by a licensed physician or dentist and rendered under the provisions of the Medical or Dental Practice Act. I understand that Summit Pediatric Therapy will not be liable for any first aid treatment, medical or hospital care, medications or surgical procedures rendered pursuant to this consent.

As with the transmission of any communicable disease, like a cold or flu, you may be exposed to COVID-19, at any time or place. As we move forward with the re-opening of our clinics for live, in-person therapy sessions, please be assured that we operate at the highest standard of care with all state and federal regulations and recommended universal, personal protection equipment, as well as, disinfection protocols to limit transmission of all diseases in our office. Despite our careful attention to sterilization, disinfection, and all other recommended safety protocols, there is still a chance that you may be exposed to an illness in our clinics, in the same way that you might be at your gym, grocery store, church, or favorite restaurant. Although we have taken measures to follow social distancing in our practice, due to the nature of therapy procedures and practices we provide, it is not possible to maintain social distancing between the patient, therapist, therapist assistants, and sometimes other patients at all times. Please rest assured that the risk of exposure is very low.

If you have been exposed to a communicable disease, you may spread the disease to the therapist, clinic staff, or other patients/parents in the practice. Therefore, we want to confirm the following statements are true:

• You, your child, or others accompanying you to Summit Pediatric Therapy appointments, or other recent acquaintances, have NOT tested positive for, or been diagnosed as having COVID-19, or any other communicable disease in the last two (2) weeks.
• You, your child, or others accompanying you to Summit Pediatric Therapy appointments or other recent acquaintances do NOT have a fever (above 100.4 degrees), cough, persistent pain, pressure, or tightness in the chest, shortness of breath, or trouble breathing.
• You, and/or your child, understand there is a higher risk for developing severe complications from COVID-19 for older adults and those who have sever underlying medical conditions like heart or lung disease or diabetes.
• I understand this consent agreement and the terms of same may change at any time, as this situation continues to evolve and/or change daily.

I understand that by signing this, I am CONFIRMING that I have read, understand, and attest to the above statements thereby accepting the risks of being seen for speech, occupational, physical, and/or feeding therapy sessions and treatment.