ACKNOWLEDGEMENT OF RISK

In consideration of the services of Advanced Therapy Clinic LLC. their officers, agents, employees, and stockholders, and all other persons or entities associated with those businesses (hereafter collectively referred to as “ATC”) I agree as follows: Although ATC has taken reasonable steps to provide me with appropriate equipment and skilled guides so I can enjoy an activity for which I may not be skilled, ATC has informed me this activity is not without risk. Certain risks are inherent in each activity and cannot be eliminated without destroying the unique character of the activity. These inherent risks are some of the same elements that contribute to the unique character of this activity and can be the cause of loss or damage to my equipment, or accidental injury, illness, or in extreme cases, permanent trauma or death. ATC does not want to frighten me or reduce my enthusiasm for this activity, but believes it is important for me to know in advance what to expect and to be informed of the inherent risks. The following describes some, but not all, of those risks. The hazards of walking on uneven terrain, slips and falls; slipping and falling on the rock wall, crashing on trampoline, falling from the swing, being hit by a ball or toy, falling from a chair, choking, allergic reaction; my own physical condition and the physical exertion associated with these activities. I am aware that ATC entails risks of injury or death to any participant. I understand the description of these inherent risks is not complete and that other unknown or unanticipated inherent risks may result in injury or death. I agree to assume and accept full responsibility for the inherent risks identified herein and those inherent risks not specifically identified. My participation in this activity is purely voluntary; no one is forcing me to participate, and I elect to participate in spite of and with full knowledge of the inherent risks. I acknowledge that engaging in this activity may require a degree of skill and knowledge different from other activities and that I have responsibilities as a participant. I acknowledge that the staff of ATC has been available to more fully explain to me the nature and physical demands of this activity and the inherent risks, hazards, and dangers associated with this activity. I certify that I am fully capable of participating in this activity. Therefore, I assume and accept full responsibility for myself, including all minor children in my care, custody, and control, for bodily injury, death, or loss of personal property and expenses as a result of those inherent risks and dangers identified herein and those inherent risks and dangers not specifically identified, and as a result of my negligence in participating in this activity. I have carefully read, clearly understood, and accepted the terms and conditions stated herein and acknowledge that this agreement shall be effective and binding upon me, my heirs, assigns, personal representative, and estate and for all members of my family, including minor children. 

 

Authorization For Treatment

I consent to the treatment necessary for the above named patient, including physical therapy, occupational therapy, speech therapy, behavior analysis/therapy and/or any other related services that the provider or physician advise to be necessary.

Payment/Insurance Authorization

I authorize for all insurance/Medicaid payments to be made directly to Advanced
Therapy Clinic LLC for therapy services rendered. I acknowledge that I am financially responsible for all charges not covered by this assignment. I further acknowledge that my insurance company may limit therapy benefits. I will be responsible for all charges accrued if my insurance denies service. I authorize Advanced Therapy Clinic LLC to release to the Social Security Administration, its intermediaries or carrier's information needed for the claim or any related Medicare Claim. 

If a Patients outstanding bill reaches $700.00 (or more) Tx. can be placed on HOLD
effective immediately. Patients treatment time will be held for 2 weeks to allow for
outstanding bill to be paid down 50% after which, treatment will resume. If the bill is not paid down to 50%, patient will be removed from schedule.

Private Pay rates are available for families with no insurance/inactive insurance or with insurance that does not cover services. Please see the front desk for more
information. Private Pay rates are not available to families that have active insurance.

Thank You! 

Appointments are scheduled into available standing appointment slots. Once you have been scheduled into an appointment time, the therapist has committed this time to you. All scheduling must go through the front office.

 

• If you are unable to keep a scheduled appointment, you must give ample notice (within 24 hours of the appointment time). It is important to note that any cancellation calls should be directed to the front office and not the clinicians. This helps ensure effective communication and timely management of scheduling adjustments. Thank you for your cooperation and understanding.
• Missing or cancelling any 3 appointments out of 5 continuous appointments will result in your child. being immediately removed from the schedule. More than 1 no-show may also result in your child being immediately removed from the schedule.
• We strongly encourage and expect the scheduling of makeup appointments in order to stay on pace with the clinicians’ Plan of Care (POC) recommendations. It is crucial for your child’s progress and success that any missed sessions are promptly addressed through makeup appointments, ensuring consistency and advancement aligned with the recommended treatment plan.
• As we prioritize the seamless continuation of care, in the event that a clinician needs to cancel, we are committed to making every effort to reschedule the patient promptly with another clinician. This ensures that patients can consistently progress along their plan of care. Our clinicians engage in ongoing collaboration to maintain familiarity with each other's patients, promoting a cohesive and supportive environment for our clients.
• As in accordance with clinic policy and for the respect of patient, no children (other than those being treated by the therapist) are allowed in the gym or treatment rooms. Please keep any visiting children in the waiting area.
• If the parent or guardian leaves the clinic during the patient’s session, they must return 5 minutes prior to the end of the session. Therapists and office staff cannot be held responsible for children beyond the scheduled therapy time.

Please Note: Therapists are only paid when your child is present. Due to limited scheduling availability, we ask that all patients attend their scheduled treatments. When an appointment is applied to our schedule, that time is reserved to meet your child’s needs. We work hard to accommodate each of our patients. Continuous neglect to follow the regulations stated in this policy could lead to termination and/or change of status to your remaining treatments and/or sessions. Thank you in advance for your understanding and cooperation in this matter.

I give Advanced Therapy Clinic LLC my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations such as quality reviews. Communication may be include, but is not limited to hospital, medical service company, health care company, insurance company, workers compensation carrier, welfare departments, patients’ employer, previous speech clinics, school teachers/aids/administrators. I have been informed that I may review the practice/clinic's Notice of Privacy Practices for a more complete description of uses and disclosures before signing this consent. I understand that this practice/clinic has the right to change their privacy practices and that I may obtain any revised notices at the practice/clinic. I also understand that I may revoke this consent at any time by making a request in writing, except for information already used or disclosed. All information obtained will be kept private and used only for the planning of services or for
billing for services provided.

At Advanced Therapy Clinic (ATC), we are a multi-specialty clinic committed to providing the most effective care for our clients. To ensure optimal treatment outcomes, there may be instances where information is shared between clinicians. This collaborative approach allows us to integrate various therapeutic perspectives and tailor our interventions to best meet the needs of each individual. By signing this form, you, as the parent or guardian, agree to the sharing of relevant information between clinicians. Please note that all information is handled with the utmost confidentiality and in strict accordance with HIPAA laws.

 

Thank you for taking the time to fill out this form as completely and honestly as possible. Your input plays an important role in the evaluation process. All the information on this form is confidential and will not be released without your permission.