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  • Patient Form

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  • Consent to Treatment & Practice Policies Agreement

  • NATURE OF RELATIONSHIP: We serve families holistically with a variety of therapeutic disciplines including speech, occupational, physical, and mental health. Sessions will be provided in the natural environment, or via teletherapy platforms. Sessions will also include family or caregiver interaction and education for continued practice of skills learned in between therapy sessions. This may include coaching caregivers in ways to modify child behavior, increase compliance, and develop self-esteem and it could include sessions with goals for the caregiver.

  • 24 HOUR CANCELLATION POLICY: If there is a need to cancel or reschedule my appointment, I understand that I need to contact my assigned Moonbug therapist immediately. If this cancellation happens with less than 24 hours’ notice, it may be considered an unexcused absence. I understand that if an unexcused absence occurs more than three times, the therapist can terminate services.

    (Parent/Guardian Initials) *   

  • CONTACT POLICY: I understand that communication with Moonbug Therapy will be directly with my assigned therapist. In the event of a crisis, I understand that I should call the appropriate emergency authorities or report to the nearest emergency room for intervention services. I understand my therapist will discuss their individual crisis response process with me.

    (Parent/Guardian Initials) *   

  • TERMINATION: I understand that both Client(s) and or treating Therapist(s) can terminate therapy services at any time.

    (Parent/Guardian Initials) *   

  • PHOTO CONSENT: I grant permission to Moonbug Therapy to use photograph(s), video or electronic media images of myself or child as it relates to therapy. I give permission for these to be displayed on social media, for educational purposes, and displayed on Moonbug promotional materials.

    Consent to Photos: (Parent/Guardian Initials)    

    Opt-Out of Photos: (Parent/Guardian Initials)    

  • RECORD SECURITY: I understand Moonbug Therapy will maintain a complete and adequate electronic patient record for each patient served, including all health and mental health information obtained or created. The records will be stored and maintained in such a way that ensures security and confidentiality.

    (Parent/Guardian Initials)     

  • CONFIDENTIALITY: Moonbug Therapy recognizes that the Client(s) will discuss confidential information during in person and virtual sessions. I understand that my Moonbug Therapist will not at any time, either directly or indirectly, voluntarily disclose, or communicate this information to a third party or disclose of the relationship between Client and Moonbug Therapist. The limitations of this confidentiality agreement include the disclosure of participation in illegal activities, all forms of abuse, or plans to harm self or others.

    (Parent/Guardian Initials) *   

  • WAIVER OF LIABILITY: On my own behalf and on behalf of my child/children and our respective heirs, admin, volunteers, executors and successors, and assigns, hereby covenant not to sue, and forever release and hold harmless Columbia Speaks, LLC DBA Moonbug Therapy and its officers, directors, employees, contractors, volunteers or agents from all liability for any and all damages or injuries suffered while under the instruction, supervision or control of Columbia Speaks, LLC DBA Moonbug Therapy, including, without limitation, those damages or injuries resulting from acts of negligence on the part of Columbia Speaks, LLC DBA Moonbug Therapy and its officers, directors, employees, contractors, volunteers or agents and also including, without limitation, injuries that were sustained because of my own negligence. I agree to specifically assume all risk of injury for myself and children participating in services or events at Columbia Speaks, LLC DBA Moonbug Therapy and hereby waive any and all claims or actions that may arise against Columbia Speaks, LLC DBA Moonbug Therapy or its officers, directors, employees, contractors, volunteers or agents as a result of such injury.


    (Parent/Guardian Initials) *   

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  • Moonbug Therapy Financial Policy

    Please read carefully and notify us if you have any questions.

  • Medicaid Beneficiaries
    Moonbug Therapy is a Medicaid-approved provider of private rehabilitation/therapy services. We currently accept patients in all Medicaid plans.

    *  I understand I need to immediately notify Moonbug Therapy if the patient’s Medicaid plan is going to change. It is the responsibility of the patient/family to provide all insurance information including multiple policy coverage. Should any information, including plan or member ID, change, it is the responsibility of the patient/family to inform our staff.
     

  • Patients with Private Insurance as Primary and Medicaid or Babynet as Secondary Insurance

  • *  I understand Moonbug Therapy is a non-participating provider with all private insurance companies (i.e. BCBS, Cigna, Aetna, etc.). This means that the provider has chosen not to participate in the these plans or accept their allowable rates.
     

  • *  I understand the non-par relationship holds the patient/family responsible for providing all claims information to the office of Moonbug Therapy.
     

  • *I understand any payment issued by private insurance directly to the patient/family for services provided by Moonbug Therapy should be paid upon receipt to the company PayPal account. A picture of the check & supporting documents must be sent to payments@moonbugtherapy.com. Other accommodations for sending payment can be made if necessary.
     

  • * I understand that the continuation of services is contingent on my complying with relaying needed information. Failure to do so may result in delay of treatment, denial of claims or discontinuation of services due to non-compliance.

  • It is the responsibility of the patient/family to provide all insurance information including multiple policy coverage. Should any information, including plan or member ID, change, it is the responsibility of the patient/family to inform our staff.

  • *  I agree to notify Moonbug Therapy of any changes to my child’s insurance coverage and understand that I am financially responsible should I fail to comply with this rule or forward necessary payments.

    * I agree to all other terms in this agreement and authorize Moonbug Therapy to bill for services and release all necessary medical information to Medicaid and my other insurance policies if applicable. 
     

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  • HIPAA POLICY
    NOTICE OF PRIVACY PRACTICE

    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.

    The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by Moonbug Therapy in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the client, significant new rights to understand and control how your health information is used. Moonbug Therapy is required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. HIPAA provides penalties for covered entities that misuse personal health

    As required by HIPAA, Moonbug Therapy has prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health

    Treatment 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.

    Payment means 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.

    Health care operations include 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 create and distribute de- identified health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

    You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

    1. The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosure to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing t
    2. The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
    3. The right to inspect and copy your protected health information. The right to amend your protected health information.
    4. The right to obtain a paper copy of this notice from us upon request

  • This notice is effective as of April 14, 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from

    You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaints with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

    Please contact the following for more information: The U.S. Department of Health & Human Services Office of Civil Rights 200 Independence Avenue, S.W. Washington, D.C. 20201 (202) 619-0257

    I have received the HIPAA Policy:

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  • Record Release

    I have been informed of the use and release of information collected through services received in regards to:

  • 1. Moonbug Therapy

  • I request that payment of authorized Medicaid and third-party payer’s benefit be made to Moonbug Therapy on the patient’s behalf for services furnished to the patient. I hereby consent to the release & disclosure of the patient’s personal health information when needed to determine benefits payable for related services.

    I consent to have my child treated by Moonbug Therapy.

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