I certify that I, and/or my dependents have insurance coverage described above and authorize payment directly to Jodi Gilray Pediatric Therapy or all insurance benefits, if any, otherwise payable to me for services rendered on my behalf or my dependents. The above-name may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining benefits payable for related services. I authorize the use of my signature on all insurance submissions.
Please list any medications and dosage. Include prescription, over the counter, herbals, vitamins/minerals, dietary supplements.
1. Regular attendance is required of all patients scheduled as patients will not benefit from sporadic therapy. We do our best to accommodate all patients but after school appointments are our busiest time and we ask that you consider varying your time of appointments as able.
2. Scheduling Policy: Scheduling is done on the first day of the month for the following month by calling into office and leaving a message. You will be called back same day by someone who will schedule your child. There are exceptions for new patients.
3. Cancellation Policy: If a patient is unable to keep an appointment for a therapy session, the clinic should be notified a minimum 24 hours in advance. The voicemail is available 24 hours a day. Please state the reason for cancellation. Appointment reminders are texted as a courtesy to families the day before their appointment to allow us time to move through our waitlist and help another child receive therapy.
4. Flex Schedule Policy: Because we do not charge for missed appointments and we try to accommodate all patients, we hold our cancelation policies strictly. Patients with 2 cancelations in an 8 week period without minimium notice will be placed on our flex schedule meaning your child will only be scheduled 1-2 weeks in advance. Your future appointments will be offered to children on our waitlist. Our front office will do their best to notify you of openings in the schedule and offer them to you but it is your responsiblity to call our office and ask about scheduling your child. After 2 months of flex schedule with good attendance, there is option to return back to advanced scheduling.
5. When patients are consistently late, the therapist has the discretion to treat or cancel appointment.
6. Parents/guardians can observe sessions as desired. Parents are not required to do so unless requested by the therapist for therapeutic educational purposes. Children over the age of 2 years generally perform better without the parent in the room. Parents are encouraged to remain on the premises should a need arise.
7. MercyCare does not permit biological parents to attend therapy sessions and they will be asked to wait in the waiting room should they arrive.
8. AHCCCS provides free transportation to all medical appointments with 3 days advance notice.
7.Please feel free to contact management if special consideration is needed, or if you have any questions regarding these policies.
My signature below indicates that I have read, understand and agree to the terms of the scheduling and attendance policies.
Our practice is required by law to maintain the privacy of your health information. We are dedicated to maintaining the confidentiality of your health information.
1. I understand that I have the right to ask and have any questions answered prior to receiving treatment, including any risks or alternatives to the treatment plan that has been prescribed by me. By signing below, I consent to have a therapist employed at Jodi Gilray PT, PLLC provide treatment. Should I be unable to bring my child in for therapy, a signed release to have a friend/family member bring child in will serve as my consent to treat.
2. Jodi Gilray PT, PLLC and its employees/contractors are authorized to use or disclose health information that is pertinent or required for therapy purposes. I have a right to a paper copy of the Notice of Privacy Practices at any time.
3. I understand that Jodi Gilray PT, PLLC may be disclosing protected health information to a patient's insurance company and physician for continuing care. I also understand that the information used or disclosed may be subject to multiple disclosures by the individual or facility receiving the information. Upon written request, I have a right to a copy of my child's health information, including medical records and billing records and may be charged the reasonable cost based fee imposed by Jodi Gilray PT, PLLC.
4. I may revoke the authorization by notifying Jodi Gilray PT, PLLC in writing. However, I understand that any action taken previously to revocation of this authorization cannot be reversed, and my revocation will not affect those actions. The authorization expires when a patient is discharged by Jodi Gilray PT, PLLC or when written notice to revoke authorization is received. Prior notification will be given to the parent or guardian before information is released.
5. I do hereby give my consent for speech, occupational and physical therapy at Jodi Gilray PT, PLLC according to the guidelines established by the referring physician and the therapist. In doing so, I understand, acknowledge and affirm that such rehabilitation and related services may involve bodily contact, touching and/or direct contact.
6. I, as parent/guardian of minor receiving treatment, 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.
7. I know and agree that Jodi Gilray PT, PLLC is not responsible for loss or damage of personal valuables.
8.Health Care Operations. Our practice may use and disclose your medical information to operate our business. These uses and disclosures are important to ensure that you receive quality care and that our practice is well run. As examples, we may use and disclose information via credit card processing or online medical scribes to conduct operational, cost-management and business planning activities for our practice. Further we may disclose your information to doctors, nurses, medical students and other personnel for continuity of patient care purposes.
I hereby authorize treatment and use/disclosure of protected health information about my child as described above.
Jodi Gilray Pediatric Therapy is dedicated to proving quality affordable healthcare to all patients. Please check a box that applies to your insurance/payment options below. By checking a box in the desigated options below you are confirming the type of insurance that you will be using.