Therapy Registration Form

I give my consent for evaluation and treatment; authorize the release of necessary information to insurance carriers and appropriate personnel. I understand our developmental assessments are not a medical checkup and do not determine IQ scores.

I understand that Sisu of Georgia, Inc. bills insurance as a courtesy and that in no way by billing my insurance do they guarantee that payment will be made by my insurance carrier.  Understanding my insurance benefits is my responsibility. 

If your insurance plan includes a co-payment, co-insurance, or deductible, you are financially responsible for these amounts at the time of service. All families are required to keep a valid payment method on file, which will be charged accordingly.

This policy applies to all therapy services, including those provided to students during the school day.

If you are unable to pay the full amount at the time of service, please speak with our Therapy Coordinator. Flexible payment plans are available, and we are committed to working with families to ensure that cost is not a barrier to care. We welcome open and respectful conversations about financial concerns—our priority is ensuring your child receives the therapy services they need.

I understand that it is my responsibility to notify Sisu of Georgia, Inc. immediately of any changes to my insurance coverage. This includes, but is not limited to: changes in insurance carriers, the addition of secondary coverage, changes in plan details with the same carrier, application for Katie Beckett Medicaid, or transitions between Medicaid plans (e.g., WellCare, Amerigroup, Peach State, CareSource), as well as any other insurance modifications not specifically listed.

I acknowledge that some insurance providers require prior authorization for therapy services. Failure to obtain the necessary authorization may result in a denial of payment by the insurance carrier.

If I fail to provide timely and accurate insurance updates and a claim is denied as a result, I understand that I will be financially responsible for all related charges.

Please attach a front and back picture of your insurance card. 

CONSENT FOR TREATMENT                                                                          

I hereby authorize Sisu of Georgia, Inc. to provide services as prescribed by my physician. I understand this consent is valid from the date of the initial evaluation session by Sisu of Georgia, Inc. and that I may withdraw my consent at any time by notifying Sisu of Georgia, Inc.

TREATMENT OF MINORS   *Outpatient *                                       

I, as parent/guardian of a minor receiving treatment, hereunder, do hereby agree and understand that I have been advised to remain on the premises during any such treatment and waive any claim I may have resulting from failure to do so.

LIABILITY                                                                                                        

I know and agree that Sisu of Georgia, Inc. is not responsible for loss or damage to personal valuables.

WAIVER AND RELEASE                                                                                 

I hereby release, discharge, and acquit Sisu of Georgia, Inc., its agents, representatives, affiliates, employees, or assigns of and from any and all liability, claim, demand, damage, cause of action, or loss of any kind, arising out of or resulting from my refusal to accept, receive, or allow emergency and or medical services, including but not limited to ambulance service, emergency care, first aid care, or physician services.

AUTHORIZATION OF PAYMENT 

I hereby assign all benefits directly to Sisu of Georgia, Inc. and also authorize release of any medical records necessary to facilitate my treatment to process medical claims and as otherwise permitted or required in the Notice of Privacy Practices. I understand fully that in the event my insurance company or financially responsible party does not pay for the services I receive, I will be financially responsible for payment.

AUTHORIZATION OF PAYMENT/MEDICAID BILLING                          

I authorize Sisu or Georgia, Inc to bill all of my units of OT/ST/PT each month to Medicaid, Amerigroup, PeachState, and/or CareSource. By initialing I am confirming that no other facility or school will be charging those units specified and that if this does occur that I will be financially responsible for the original authorized amount due to Sisu of Georgia, Inc. If I become financially responsible for such charges, I understand that I would be eligible for the initial scholarship rate of 40% and a higher level based on financial assistance application.

NOTICE OF PRIVACY                                                                               

I acknowledge receipt of Notice of Privacy Practices.

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts the assignment below.

I authorize payment of medical benefits to the undersigned physician or supplier for services described below.

We are happy you chose Sisu to help your child learn and grow and we are looking forward to helping you be an important part of that process! This is your agreement for your role in the therapy process, outlining the expectations of our therapists to set your child up for success in reaching their highest potential. Please sign below that you agree to follow the below guidelines.

Payment is due at time of service

• If your insurance policy has a co-payment or co-insurance (%), or a deductible, you are responsible for that payment at the time of service. You will be required to put a card on file that can be charged at the time of service. This includes program children being pulled from the classroom and being seen by our therapists. If you cannot afford the full amount, please see our therapy coordinator and a payment plan can be decided upon. We do not want to be cost prohibitive and we encourage open conversation regarding finances. Our goal is for your child to receive services. 

Attendance

• Consistent attendance is important for your child’s progress! Therefore, it is important and your responsibility to let your child’s therapist know ahead of time by calling the front desk or emailing therapist if you know your child will not be in attendance or arriving late. While not always possible, this gives the therapist a chance to try to make-up a missed visit if therapist's schedule allows. Examples include: doctor’s appointment, vacation, etc. 
• No show/No call appointment policy includes:
  • 1st time - freebie
  • 2nd time - charged $50.00 no show fee
  • 3rd time - your child will be moved to waitlist due to missed visits
• Outpatient families must stay on the premises during your child's therapy session(s). If you go outside/to your vehicle, please return to the lobby 5 minutes before end of a half hour session and 10 minutes before end of an hour session so therapist has time to discuss progress and home activities before their next appointment.
• Outpatient Late Policy - Late arrival / late pick up appointments will be charged a $10 fee after 15 minutes of being late. A $5 increase will apply after every 5 minutes you are late in addition to the $10 initially after 15 minutes. After 5 late arrivals / pickups your child will be moved to the wait list. Each patient gets "one free pass."

Illness/Injury

• If your child has an illness/injury that prevented them from attending school, they do not need to attend therapy that day. They may return to therapy after illness when symptom-free (fever, vomiting, diarrhea, etc.) for 24 hours without medication.
• Your child must have written physician clearance to resume therapy services following surgery, serious injury, or hospitalization.

Communication

• Please complete and return all paperwork within a timely manner. Return paperwork the following appointment for outpatients or complete within 72 hours for items sent home and electronic questionnaires.
• For children who are enrolled in Sisu's preschool program: Check backpack and electronic parent communication (Procare) daily for notes from your child's therapist.

Transitioning Due to Age 

• Sisu's preschool program / therapy services focuses on treating kids aging from 6 weeks - 6 years. Due to the age range Sisu works with, there may come a time (after the age of 6) or when your child graduates from Sisu that your child may be better served elsewhere in order to make steady progress toward goals at a more age appropriate clinic. There are several factors that therapists take into consideration when deciding if your child may be better served at a more traditional outpatient facility. The following items include: childs age, childs size, childs cognitive level, and childs social - emotional level are taken into consideration and transition to another facility is at each individual therapist’s discretion with assistance provided in suggesting facilities and making the transition as easy as possible.

Sisu has created a therapy social media page to highlight the awesome achievements of each of our therapy kiddos. We will also be posting home activities, educational information, and announcements. Please choose one of the choices below. 

Sisu is a place that welcomes college and high school age students to come and volunteer and / or shadow in order to learn more about Sisu and what are mission is. Sisu also has partnerships with several local universities that allow their therapy programs to use Sisu as a clinical site which means if your child receives therapy services here at Sisu a student may interact, play, or lead therapy with them. In addition, the student will have access to your child's therapy-related medical records (evaluations and plans of care) for planning and implementation of treatment. Please sign below if giving consent that your child may be observed by these student(s), have access to therapy related medical records, and / or have these students work with your child during their regular scheduled sessions. Having students work with your child is a great opportunity as not only are we assisting in their education, they are bringing fresh ideas and perspectives to our practice as well.