CONSENT TO TREAT: I (parent or guardian), for the patient named above hereby consent to such medical treatment and diagnostic procedures as beneficial and appropriate for the patient's condition or illness based on the judgment of the physician(s), to be performed by the health care provider(s I have had, and will continue to have, an opportunity to discuss treatment options with my health care provider, ask questions regarding such treatment options, and understand the options discussed.
RELEASE OF MEDICAL INFORMATION: I hereby authorize Little Champs Therapy & Yoga to release any and all pertinent information contained in my medical records (current and prior) for: Treatment: Includes activities performed by health care practitioners in providing, coordinating, or managing care with third parties and consultations with other health care providers. Payment: Includes activities involved in receiving payment for services rendered and any review of care for medical necessity, justification of charges, and pre-authorizations.
NOTIFICATION OF INSURANCE COVERAGE: I hereby agree to notify Little Champs Therapy & Yoga) of any change in insurance coverage including changing insurance provider, adding, or removing insurance company, coordination of benefits, notifications of eligibility or ineligibility to current insurance provider, or any changes that may affect. Failure to notify us of such a change may incur financial liability.
APPOINTMENT CANCELLATION POLICY: Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in your therapist's schedule that could have been filled by another patient. As such, we require 24 hours' notice for any cancellations or changes to your appointment. Patients who provide less than 24 hours notice, or miss their appointment, will be charged a cancellation fee.
PAYMENTS: Payment is due in full at the end of each session. You are responsible for any outstanding balances and/or co-pays for services rendered including any portion not covered by your insurance. You authorize charges to your credit card and the charge will appear on your credit card statement. You certify that you are an authorized user of the Credit Card and will not dispute these scheduled transactions; so long as the transactions correspond to the terms indicated in the authorization form.
TRAVEL FEE: Any clients receiving treatment outside of our three facilities (in West Palm Beach, Delray, and Boca Raton) are required to pay a $20 travel fee per appointment.