If my child becomes ill or involved in an accident and I cannot be contacted, I authorize the following hospital or my child's physician to give emergency medical treatment required.
What does your child eat for...
Does your child use the following tools:
I. CONSENT FOR SERVICES
I give permission for Skills on the Hill, LLC to provide evaluation, treatment, and/or consultative services to
II. CONFIDENTIALITY POLICY At Skills on the Hill, we are committed to maintaining client confidentiality. However, due to space constraints, we are unable to meet with each of our clients in a private room at the end of each session. Therefore, we use the waiting room to provide you with information about your child’s therapy session and home recommendations. We understand that you may prefer an alternative arrangement. If so, please let us know and we will accommodate you. If you prefer, you can schedule a meeting or phone consult with your child’s therapist every 1-2 months in place of one of your child’s sessions or in addition to his/her session.
II A. PHYSICIAN PLAN SHARING At Skills on the Hill, we are committed to maintaining client confidentiality. We recommend sharing the child's evaluation results with the referring provider/physician.
III. PERMISSION TO PHOTOGRAPH I hereby give my permission to Skills on the Hill, LLC, and their staff to photograph or videotape my child. I understand that photos/videos will be used for educational/promotional purposes. I specifically waive any rights to compensation with respect to my child’s name, likeness, picture and/or voice.
I, ____________________________(parent/guardian), give my permission to Skills on the Hill, LLC to exchange information (either in writing or orally) about ________________(child), whose date of birth is_____________________, with your insurance provider(s), physicians, programs, teachers, or other persons. (Please include contact information for ALL professionals working with the child):
This will release Skills on the Hill, LLC from all legal liability that may arise as a result of their compliance with my request.
V. CANCELLATION & ATTENDANCE POLICY As you and your child have made the commitment to therapy, we have made the same commitment to you in reserving your scheduled weekly time slot(s). Excessive absences affect your child’s rate of progress and take away valuable therapy time another child may need who is on our waiting list. We expect clients to consistently attend scheduled appointments. Please give us as much advance notice as possible if you need to cancel an appointment. This includes changes in schedules due to school fieldtrips, vacation plans, and medical appointments. A cancellation made within less than 24 hours or a missed appointment, including evaluations, will be charged $80.00. When an appointment is rescheduled within the same week/the following week, the cancellation fee will be waived. If a child misses more than 25% of scheduled appointments for two months in a row, the child will lose his/her permanent weekly appointment time and be given the choice to be on our flex scheduling program which offers more flexibility. Exceptions to this policy will be made in the event of an emergency or illness. Please do not bring a sick child to therapy. A child must be free of fever, pink eye, lice, or diarrhea for 24 hours before resuming OT sessions. He/she will not be able to perform at his/her full potential. No charge will be applied for a therapist cancellation. We will make every effort to make up such sessions. If there is a Federal Holiday (usually occurring on a Monday) or school is canceled because of weather conditions, assume that Skills on the Hill will be open unless you are contacted by your child’s therapist to cancel or reschedule treatment. Skills on the Hill is a medical practice and we do not follow the typical school calendar.
VI. PAYMENT POLICY AND INSURANCE In an effort to help families with insurance reimbursement for therapy expenses, Skills on the Hill will obtain authorizations for therapy services (when required) and submit claims electronically to your insurance carrier on your behalf. This does not mean we have a contract with every insurance, as we are still out of network with most insurance. However, your claims submission will be timely, and our billing department will follow-up on any unpaid claims issues. After insurance reimbursement, you will never be out-of-pocket more than our current self-pay rate for services (please see attached Fee Schedule) Using the Verification of Benefits form, our billing office will verify your insurance benefits and talk to you about them via phone. Our billing staff is experienced with therapy services and they will be able to answer all of your questions related to benefits, claims processing, as well as your billing statements. Please be available to them so that you can have all of your questions answered. You will not be billed until your claim has been processed by your insurance. You will receive a statement from us every 28 days if you have a balance due. You will then have (5) days to review the statement and call the billing department with any questions/concerns about the charges. Unless there are corrections, your credit card will be charged for the full amount shown on your statement. For our BCBS families: In most cases, the payment for services will be sent directly to you. Please be looking for your payment and deposit the check directly into your bank account. The billing office will verify with the insurance company the specific amount of the reimbursement paid to you, then they will send you a statement to reflect payments and charge your credit card. I understand that occupational therapy services must be medically necessary in order for insurance to consider coverage and that information in my benefits manual does not guarantee coverage. I also understand that service may or may not be covered by my health plan. I agree to pay the current patient responsibility rate for any occupational therapy services that are non-covered.
It is our pleasure to provide high quality pediatric OT services to your child(ren). We know that submitting the claims to your insurance for you relieves you of having to work on your own for insurance reimbursement. For questions, please contact our Billing Office: 202-424-2718 or firstname.lastname@example.org. Our regular therapy staff will not be able to answer your questions or discuss your insurance claims or your statements as they are not involved with the insurance processing.
*** SELF-PAY FEE SCHEDULE ***(Effective 1/1/2020)
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: • Provide treatment and services • Bill and collect payment from you, your insurance company, or a third-party payer • Conduct healthcare operations such as assess my care and outcomes as well as quality assessments I have received, read, and understand your Notice of Privacy Practices containing a more complete description of my rights and the uses and disclosures of my health information. I understand that Skills on the Hill has the right to change its Notice of Privacy Practices and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that Skills on the Hill restricts how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand that this organization is not required to agree to my requested restrictions, but if the organization does agree then it is bound to abide by such
******************PLEASE KEEP A COPY FOR YOUR OWN RECORDS*********************NOTICE OF PRIVACY PRACTICES This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions about this notice, please the contact Facility Privacy Official Kristen Masci at (202) 544-5439. Our Responsibilities We are required by law to maintain the privacy of your health information and provide you with a description of our privacy practices. We will abide by the terms of this notice. Uses and Disclosures The following categories describe how we may use and disclose your medical information. For Treatment: We may use health information about you to provide you treatment or services. This means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical examination. For Payment: We may use and disclose health information about your treatment and services for such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment. For Health Care Operations: Members of our staff may use information in your health record for the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review. We may disclose information to students for educational purposes. We may remove information that identifies you from this set of health information to protect your privacy. We may contact you to remind you that you have an appointment; assess your satisfaction with our services; tell you about possible treatment alternatives; tell you about health-related benefits or services; and we may leave messages on your answering machine or voice mail regarding primary appointment reminders and billing/ collections efforts. Future Communications: We may contact you in the future via newsletters, mail outs, or other means regarding treatment options, health related information, or other community-based initiatives or activities our facility is participating in. Organized Health Care Arrangement: This facility and its staff members have organized and are presenting you this document as a joint notice. Information will be shared as necessary to carry out treatment, payment, and healthcare operations. Therapists and caregivers may have access to protected health information in their offices to assist in reviewing past treatment as it may affect treatment at the time. Law Enforcement/Legal Proceedings: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing, and weare required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. Your Health Information Rights Although your health record is the physical property of the healthcare practitioner or facility that compiled it, you have the right to: Inspect and Copy: You have the right to inspect and obtain a copy of your health information, including billing records. Amend: If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our facility. Any request for an amendment must be sent in writing to the Facility Privacy Official. An Accounting of Disclosures: You have the right to request an accounting of disclosures. This is a list of certain disclosures we make of your health information for purposes other than treatment, payment, or healthcare operations where an authorization was not required. Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or healthcare operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care (i.e., family member or friend). Any request for a restriction must be sent in writing to the Facility Privacy Official. We are required to agree to your request only if 1) except as otherwise required by law, the disclosure is to your health plan and the purpose related to payment of health care operations (and not treatment purposes), and 2) your information pertains solely to health care services for which you have paid in full. For other requests, we are not required to agree. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. Request Confidential Communications: You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we contact you at work instead of at home or in a private room, rather than in the waiting room. The facility will grant requests for confidential communication at alternative locations and/or alternative means if the request is submitted in writing and the written request include a mailing address where the individual will receive bills for services rendered by the facility and related correspondence regarding payment for services. Please realize, we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location. A Paper Copy of this Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Changes To This Notice We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted in the facility and on our website and include the effective date. Complaints If you believe your privacy rights have been violated, you may file a complaint with this facility. You may also file a complaint with the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint. Other Uses of Health Information Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us with permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you and documented in our facility.