Treatment Agreement: I hereby agree to treatment with Moving Mountains Therapy Center, PLLC as prescribed by my physician. I understand Moving Mountains Therapy Center partners with Eat.Move.Grow., S-Corp (occupational therapy and mental health) and Stack Speech Therapy Group, S-Corp (speech therapy and physical therapy) to provide clinical treatment services.
Waiver of Liability: I give permission to participate in Moving Mountains Therapy Center’s programs and services. I hereby release Moving Mountains Therapy Center’s principal owners, therapists, employees and representatives, and all other individuals or organizations acting on behalf of Moving Mountains Therapy Center, from any and all claims which I or my dependent may have, resulting from or in connection with participation in Moving Mountains Therapy Center’s programs. This includes, but without limitation, any claim, demands, or causes of action for injuries to myself (or dependent), including but not limited to injuries resulting from the use of any therapy equipment during the program at the Moving Mountains Therapy Center or at clients’ homes. This agreement is signed for the purpose of fully and completely releasing, discharging, and indemnifying Moving Mountains Therapy Center in connection with their programs from all liability as herein described.
Clinic, Home Visits, Teletherapy
The frequency and time of treatment are especially important to the therapeutic process and growth. Therefore, clients are given a prescribed amount of time for each therapy session and a prescribed number of sessions per week. It is important that clients arrive on time so that they can participate in the full scheduled therapy time. If a client is running late for a therapy session it is the client’s or the responsible parties’ responsibility to call and notify Moving Mountains Therapy Center. MMTC does not follow district closures for holidays. If you have travel plans, please cancel, or reschedule your appointments with the front desk. If you or a responsible party need to cancel an appointment for reasons aside from travel or will be running late, please first contact the main office at (406)-396-4130, not your clinician.
To uphold prescribed treatment plans, the following tardiness policy is enforced.
For sessions that are scheduled for 30 minutes, if a client is 15 or more minutes late the session will be canceled.
For sessions that are scheduled for 45 minutes, if a client is 23 or more minutes late the session will be canceled.
And, for sessions that are scheduled for 60 minutes, if a client is 30 or more minutes late the session will be canceled.
To provide quality service and foster the therapeutic process and growth, we ask that clients maintain a minimum of 75% attendance for therapy sessions in a 3-month period.
It is the clients’ or the responsible party for that clients’ responsibility to notify Moving Mountains Therapy Center if the client is going to be late or absent from a scheduled therapy session.
For pre-planned absences, Moving Mountains Therapy Center asks that you provide at least 24-hours’ notice of the cancellations.
For extended pre-planned absences, Moving Mountains Therapy Center requires at least 48-hours’ notice for the cancellations.
Appointment time slots for extended pre-planned absences may be held for up to 2-weeks before the appointment time slot will be opened to other families/clients.
For unforeseen events and illnesses, Moving Mountains Therapy Center asks for notice of the cancellation the morning of the scheduled therapy session. If a client is ill, we ask that the scheduled therapy sessions are canceled, and a minimum of 24-hours passes with a fever of less than 99.6 F without medication to reduce the fever.
No Call/No Show
If a client or the responsible party for a client does not show nor call for a scheduled therapy appointment, it will be considered a “no-call, no-show”. If client has more than two “no-call/no-shows” within a 3-month period that time slot will be opened to other clients/families on our waitlist. Failure to meet attendance and no-show requirements could result in loss of scheduled therapy appointments, being placed on a temporary hold, and/or being placed back on the waitlist.
Community Sites – Daycares & Schools
For clients that attend therapy services at Community Site locations Moving Mountains Therapy Center clinicians will have set therapy days and times that they are available to see clients attending a specific Community Site. Clients and/or their families will be informed of these treatment days and times at the initiation of therapy services. It is especially important that clients are at the Community Site during these set therapy times so that they can participate in their full scheduled therapy times to foster the therapeutic process and growth. For this reason, Moving Mountains Therapy Center enforces the following tardiness and attendance policies for Community Site Locations.
Clients must maintain a minimum of 50% attendance for scheduled therapy sessions during the set therapy times for that Community Site in a 3-month period. If a client is unable to maintain 50% attendance or is unable to be seen during the set treatment time they will be placed on our waitlist and the time slot will be opened to another client.
Family and Client-Centered Principles: Moving Mountains Therapy Center is focused on family and client-centered services where we view our clients and when applicable their family units as equal partners. We understand that our clients and when applicable their family units are the experts and ultimate decision-makers regarding their needs. Intervention at Moving Mountains Therapy Center focuses on strengthening and supporting the functioning of the individual and when applicable to the family unit. Thus, the therapy we offer is individualized, flexible, and responsive to the needs you have identified for yourself and/or for your family unit. When applicable we do ask that families, including parents, caregivers, guardians, other family members, or invested individuals attend the therapy sessions and be an involved partner in therapy.
Communication Agreement: By checking my choice of method(s) of communication above, I understand the following: Electronic communications such as email or text messages are not guaranteed as secure. I understand there are known and unknown risks that may affect the privacy of the client’s personal health care information when using text messaging to communicate. I understand that Moving Mountains Therapy Center will use reasonable means to protect the security and confidentiality of text information, however, text messaging is not HIPAA compliant and therefore Personal Health Information (PHI) will not be shared via text messaging and HIPAA compliant precautions will be taken to ensure the client’s PHI is protected to the best of Moving Mountains Therapy Center’s abilities. If I choose to use email or text messaging to communicate with Moving Mountains Therapy Center, I agree that if I have not received a response to time-sensitive information (i.e., rescheduling or canceling sessions, etc.), it is my responsibility to follow up in person or via direct phone call with a Moving Mountains Therapy Center staff member. I understand that Moving Mountains Therapy Center will use reasonable means to protect the security and confidentiality of email information sent and received via a HIPAA compliant encrypted email service. I agree that if I wish to withdraw my consent to use email or text communications regarding the client’s therapy services, it is my responsibility to inform Moving Mountains Therapy Center, PLLC, in written communication.
Health Policy: Help and cooperation are required in order to maintain a healthy environment. An individual must be temperature-free for 24 hours, without the aid of fever-reducing medicine, before returning to therapy. If the individual has vomited and/or had diarrhea, he/she should not return to therapy until 24 hours have passed since the last episode of the same.
Clients will NOT be seen if any of the following is present:
• Too ill or uncomfortable to function in the therapy setting;
• Continual runny nose;
• Thick or discolored nasal discharge;
• Excessive sneezing or coughing and mucus-producing cough;
• An elevated temperature.
Authorization for Release of Information: Moving Mountains Therapy Center, PLLC is hereby authorized to furnish and release such professional and clinical information as may be necessary for the completion of my medical claims by valid third party agents or agencies from the medical records compiled during treatment. Moving Mountains Therapy Center, PLLC, Eat.Move.Grow., S-Corp, and Stack Speech Therapy Group, S-Corp are hereby released from all legal liability that may arise from the release of said information.
HIPPA Release: I certify that I have received a copy of the Notice of Privacy Practices effective 4-14-13, describing the privacy regulations as outlined by HIPAA and that I understand any questions regarding this privacy notice may be directed to Moving Mountains Therapy Center, PLLC (or Eat.Move.Grow., S-Corp or Stack Speech Therapy Group, S-Corp, as appropriate). I agree that these practices have been fully explained to me, and I am satisfied that I understand its consent and significance.
Assignment and Authorization to Pay Insurance Benefits: I hereby assign and authorize payment directly to Eat.Move.Grow., S-Corp, or Stack Speech Therapy Group, S-Corp as appropriate.
Health Insurance: We participate with some insurance companies, but not all. In the event that we do not accept your insurance, we will be happy to provide you with the necessary paperwork to assist you in seeking reimbursement for out-of-network provider services. Please be advised that many health insurance plans have limited coverage for speech-language pathology services. We recommend you contact your insurance company to discuss the limits of your coverage.
Fees: To maintain your access to care we accept most insurances and have contracted with Monida Healthcare Billing Solutions, a local billing office, to be responsive to your questions in a timely fashion. If you have any questions or concerns regarding your family’s eligibility and/or co-pay, please contact Monida Healthcare Billing Solutions directly at 406-829-2390. Moving Mountains Therapy Center may offer an estimate of benefits and/or authorization as a courtesy; however, this does not guarantee a payment or verify eligibility. Payment of benefits is subject to all terms, conditions, limitations, and exclusions of the member's contract at the time of service.
Payment: The person who completes the Consent to Admission & Medical Treatment- Financial Agreement found within the Admissions Packet, is responsible for payment of all services rendered. In most cases, payment is due at the time services are rendered unless you have made other arrangements in advance. Accounts more than 60 days overdue will be subject to a $20 late fee and a 5% interest charge. Accounts that have not had sufficient payments made on them and are 90 days overdue will be sent to collection. Payment plan options are available for clients who are struggling financially and cannot afford to pay their balances in full. For clients seeking third-party reimbursement, please be aware that you are ultimately responsible for payment of all services rendered. If your insurance carrier denies payment (including recoupment) or does not remit payment within 90 days, the client will be responsible for payment of all services rendered.
Collections: I understand that in the event any unpaid balance is placed for collections with any third-party collection agency a fee of 50% of the unpaid balance will be added to the total amount due. This amount shall be in addition to any other costs incurred directly or indirectly to collect amounts owed under this agreement such as court costs, attorney fees, late fees, and any other fees so stated elsewhere. The authorized fee of 50% and the additional costs and charges listed above represent the actual costs incurred by (practice name) to collect amounts owed under this agreement and a corresponding decrease in expected revenue resulting from the signer’s failure to pay as specified in this agreement.
Termination of Services: In the event, you do not keep your financial obligations to Moving Mountains Therapy Center, PLLC, and remain delinquent on your account for more than 90 days, services will be suspended until payment is received. Services may also be suspended if the total unpaid account balance totals to greater than $1000. Services may be terminated if it is determined that continued participation will be a detriment to your or your family.
I (client/legal guardian) agree to the above.