Acknowledgements and Policies

Child's Name*

Child's Date of Birth*

Date

Communication Made Easy, Inc (CME) will make every effort to work with our clients regarding obligations for services whether payment may be through insurance, private pay, co-payment or other agreements. Assignment of Benefits:

I certify that the information given by me in applying payment is correct. I hearby authorize payment by my insurance carrier of the benefits, otherwise payable to me, to be made directly to CME, Inc for their
I authorize CME, Inc to release all insurance companies and/or compenstaion carriers only such as diagnostic, therapeutic, and financial information as may be necessary to determine benefits entitled and to process payment claims for health services that will be provided. I understand and agree that I am financially responsible for all co-pays, coinsurance and amounts not covered by my healthcare provider.
I understand that I am obligated to provide ALL insurance information and must notify CME, Inc immediately should this information change. I understand that failure to comply with this policy will result in patient responsibility for any unpaid balances.

Parent/Guardian Signature*

Date*

Date

Parent/Guardian Name*

I do hereby give permission for my child to be photographed and/or videoed while attending CME, Inc., and for their photo/image, first name, and summary of their therapy progress to be shared on social media and/or CME website.I do NOT give permission for my child to be photographed or videoed by CME.

Child's Name*

Parent/Guardian Signature*

Parent/Guardian Name*

Date*

Date

Child's Name

DOB

YesNo

Child's Name

Pick up location

Address

Drop off location

Address

Contact Phone Number

Format: (000) 000-0000.

I, the legal parent/guardian of the above-named child, do hereby give my consent for CME, Inc., to transport my child to and from CME for therapy services. I understand that allowing CME, Inc to transport my child, I agree to release CME, Inc., its agents, and employees, from and against any and all liability, loss, damages, claims or actions to the maximum extent permissible by law, arising out of such transportation. I do, hereby give my consent for CME Inc., to provide treatment (on-site and off-site) during an emergency situation which may include administering CPR. If necessary, the staff will activate outside emergency services, such as 911.

Parent/Guardian Name

Parent/Guardian Signature

Date

Emergency Contact Name

Relationship to child

Emergency contact Phone #

Format: (000) 000-0000.

Please list any person who has permission to pick up your child from therapy services or from the transportation pickup/drop off location

Name 1

First and Last Name

Phone 1

Format: (000) 000-0000.

Name 2

First and Last Name

Phone 2

Format: (000) 000-0000.

Name 3

First and Last Name

Phone 3

Format: (000) 000-0000.

Child's Name

DOB

The CME staff would like to take a moment to thank you for choosing CME for your child's therapy needs. CME, Inc, has a passionate dedication to providing the highest quality therapy services to the children in our area. We ask that all families contribute to our commitment by playing an active role in the therapy process to ensure the best possible outcomes for your child. In order to best accommodate all of our patients and ensure continuity of your child's treatment we ask that you adhere to the following appointment and scheduling policies:

1. As we are growing, we will try to accommodate any changes to the time or day your child needs to be seen, but it may not be possible right away. When an available spot opens, you will be notified.

2. Please arrive on time for your scheduled appointment. If you are more than 15 minutes late for your appointment time, your appointment may need to be rescheduled.

3. For HIPPA reason, we ask that you stay in the lobby/waiting area during your child's therapy session and not access the restricted areas where therapy is being provided.

4. If you would like to leave during your child's session, please notify the therapist. We also ask that you return to the clinic 15 minutes prior to the scheduled end of the session.

5. Please cancel appointments as soon as you know you will not be able to attend. This included doctors' appointments, vacations, illnesses, etc. A minimum of 24 hours' notice is required for non-emergencies.

6. In order for your child to get the best possible results out of therapy, it is important to be consistent in keeping appointments. Patients with attendance below 75% will result in your child losing their regularly scheduled appointment time and move to a week to week schedule.

7. Repeated failure to comply with this attendance and scheduling policy may result in your child being discharged from services at CME, Inc.

We appreciate your cooperation and compliance with our attendance policy. We look forward to working together to help your child reach their full potential.

By signing below, you acknowledge that you have received a copy of CME, Inc.'s attendance policy.

Child's Name*

Date*

Date

Parent/Guardian Signature*

Parent/Guardian Name*

Acknowledgements and Policies

Media Release

Transportation and Pick up

Attendance Policy