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.  I further understand that my medical deductibles as outlined in my insurance plan are my financial responsibility.  In addition, any co-pays or co-insurance amounts due as a result of my insurance plan are my financial responsibility.  These amounts will be billed to me monthly and I understand that these amounts are due upon receipt of the bill unless a payment plan has been established with the Therapy Billing Coordinator. 

 For services not billed to my insurance carrier because they are either non-covered services or because I do not have insurance or because I choose not to have services billed to my insurance (private pay status) I understand that there is a financial scholarship available to me at the rate of 40% and that a higher level scholarship can be obtained by filling out a financial aid application and eligibility being determined.  Additional scholarship rates are determined based on financial need and will be awarded accordingly.  The maximum scholarship level is 65%.

 I understand that it is my responsibility to inform Sisu of Georgia, Inc immediately if there are ANY changes in my insurance plan which include but are not limited to: change in carriers, additional coverage (secondary insurance), change in plan with same carrier, application for Katie Beckett Medicaid, change from Medicaid to WellCare, AmeriGroup, PeachState, CareSource, or any other changes not otherwise mentioned.  Some insurance companies require a prior authorization for services and failure to obtain one can result in non payment from the carrier.  I understand that if I neglect to inform SISU of insurance changes and payment is denied due to this lack of information that I will be held financially responsible for the charges incurred. 

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.

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.