Patient Intake and Informed Consent

Beach Baby Pediatric Therapy, LLC provides early intervention, physical, music, speech, feeding and occupational therapy services, herein referred to as "Therapy" or "Therapy Services." I understand I have the right to choose my Therapy provider and I have chosen Beach Baby Pediatric Therapy, LLC, herein referred to as “BBPT.” I have given BBPT, and all personnel including contractors and employees, permission to evaluate and treat my child (biological, legal, or through guardianship) listed above and understand no guarantees have been made to me as to the outcome of treatment.

I further agree to hold BBPT, including but not limited to any of its personnel, owners, employees, contractors, officers, members, agents, representatives or directors free and harmless from any complaints, suits for damages or complications which may result from such Therapy treatment or procedures.

Gross motor play to include, but not limited to: climbing, running, hopping, jumping, riding bikes/scooters, swinging, and playing on playground equipment is often included in Therapy evaluations and treatment sessions. I expressly release BBPT from any injury resulting from gross motor play.

I understand that Therapy Services may have inherent risks associated with treatment and that I have a right to ask about these risks and have any questions answered about my child's condition or treatment, prior to the therapist initiating treatment.

I have read, or have had read to me, the above consent. I fully understand this Informed Consent and have had the opportunity to ask questions and discuss its content with BBPT.

I understand that Therapy Services held outside of the home (to include, but not limited to daycares) may lead to treatments/Therapy sessions being observed by outside parties. I am aware that conversations, names and patient information may be overhead in these situations. I consent to Therapy sessions being held at the listed address(es) above.

I authorize BBPT to bill my insurance company for all claims and for all insurance payments to be made directly to BBPT for Therapy Services rendered, without obtaining my signature on each individual claim.  I further authorize the release of all medical information necessary for each claim.

I authorize the release of any information acquired during evaluation, treatment or consultation of the named patient to appropriate agencies and clinicians.

My signature on this release fulfills CMS 1500 form lines 12 and 13. I permit a copy of this authorization to be used in place of the original

All co-payments and deductibles must be paid in full at the time of service.

Lack of payment by my private insurance company, Early Steps and/or Medicaid will result in all charges being transferred to my personal balance on my statement.

I further acknowledge that my insurance company may limit Therapy benefits and that I will be held accountable for all accrued charges. It is solely my responsibility to understand my insurance coverage.

I understand that if my insurance company requires a referral or authorization, it is my responsibility to obtain this documentation and provide it to BBPT.

In the event of any change in my insurance coverage or contact information, I agree to notify BBPT immediately. Failure to inform BBPT of any changes could result in patient responsibility for charges incurred.

I hereby agree to promptly pay my personal account balance including co-payments, deductibles and all accrued charges not covered by my insurance company upon receipt of my statement.

I understand that payment is due upon receipt of the invoice. Interest will accrue at the then standard interest rate following the 30th day.

If your payment is 30 days late, you have 30 days to pay your account in full. If a balance remains, your account may be referred to a collection agency and your child may be discharged from Therapy Services until the account is paid in full. I understand and agree that responsibility for payment for Therapy Services rendered is mine and I agree to pay such collection costs and attorney fees as may be required to effectively collect the debt.

If you are not currently insured by a plan accepted by BBPT you are welcome to take advantage of our rates of:

$225.00 for an initial evaluation
$150.00 for a re-evaluation (scheduled every 5-6 months)
$105.00/hour for treatment sessions.

BBPT is not responsible for problems between the patient and insurance company and is unable to intervene or negotiate for either party on disputed claims.

Consultations with caregivers/legal guardians and/or other providers outside of scheduled therapy sessions will incur a fee of $50 per hour. This fee will not be billed to insurance and will be invoiced directly to parent/legal guardian.

BBPT provides this form to comply with the Health Insurance Portability and Accountability Act (HIPAA). The terms of this notice may change, and you will be provided a revised copy upon request. You have the right to request restrictions on the sharing of protected health information for treatment, payment or health care options. By signing this form, you consent to BBPT’s use and disclosure of protected health information/records for evaluation, treatment, payment and for consulting with clinicians, doctors and insurance companies for claim payments and patient care. You acknowledge you have received a copy of our Notice of Privacy Practices and expressly consent to receipt of this notice electronically to the email address listed above.

We may use your information in the following ways:
To treat your child
Run our organization
Obtain payment for our services
Help with public health and safety issues
Conduct research
Comply with the law
Communicate with doctors, insurance companies and other clinicians
Address workers’ compensation, law enforcement, and other governmental requests
Respond to lawsuits and legal actions

You may revoke this consent at any time by providing written notice to BBPT. Such revocation will apply going forward and will not be retroactive.

Please provide 24 hours’ notice for cancelled sessions. Failure to do so may result in a no-show fee of $105.00.

After 1 no-show or if 25% of scheduled sessions are cancelled within a one-month time frame, your child will be discharged from Therapy Services and a letter will be sent to their primary care provider.

No-show visits, when a therapist shows up during a scheduled visit time and the family is not present, will be charged a $105.00 no-show fee.

Late arrivals from scheduled appointment time may lead to a shortened session.
We do understand that emergencies arise and will review each violation carefully.

Parent/legal guardian will contact therapist and cancel session if patient has any signs/symptoms of being contagious including, but not limited to: cough, vomiting, rash, fever, diarrhea. Therapy sessions will resume once patient has been symptom-free for 24 hours. If parent/legal guardian fails to cancel Therapy session, and therapist observes any signs/symptoms of the child being contagious, the therapist may discontinue the Therapy session and the full session fee will be charged.

Parent/legal guardian consents to receiving emails, phone calls, text messages and voicemails left on answering machines by therapist or office regarding Therapy and to promptly returning any requests from the therapist for information.

Parent/legal guardian consents to receive emails regarding promotions, materials, community classes and other updates from BBPT. 

Parent/legal guardian will refrain from scheduling other appointments during scheduled Therapy sessions.

Parent/legal guardian/caregiver over the age of 18 will be present for all Therapy sessions for the entire duration of the session.

Parent/legal guardian agrees to maintain a clean, safe and climate-controlled environment for Therapy sessions.

Patient may be discharged from Therapy Services at any time for any reason including but not limited to the following: Doctor request or recommendation, legal guardian request, achievement of plan of care goals, plateau in progress, change in insurance, per cancellation policy or at the discretion of the therapist and/or BBPT.

I understand that my health care provider wishes me to engage in a telemedicine consultation/visit.

My health care provider has explained to me how the video conferencing technology will be used to affect such a consultation/visit and will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.

I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my healthcare provider or I can discontinue the telemedicine consult/visit if it is felt that the video conferencing connections are not adequate for the situation.

I understand that if others are present during the consultation/visit other than my health care provider, they will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation/visit at any time.

I have had the alternatives to a telemedicine consultation/visit explained to me, and in choosing to participate in a telemedicine consultation/visit.

In an emergency, I understand that the responsibility of the telemedicine consulting specialist is to advise my local practitioner of the emergency and that the specialist’s responsibility will conclude upon the termination of the video conference connection.

I have had a direct conversation with my healthcare provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

By signing this form, I certify:

* That I have read or had this form read and/or had this form explained to me

* That I fully understand its contents including the risks and benefits of the procedure(s).

* That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

Parent/legal guardian grants permission to BBPT to use photograph(s), digital images or videos of my child or myself as it relates to Therapy Services. I grant permission to BBPT to use the photograph(s), digital images or videos including voice and physical surroundings without restriction or compensation to send to me via email, mail or text; for promotional material (including websites, printed material, brochures, videos or other media) and for educational purposes (including discussion with appropriate agencies and clinicians).

Parent/legal guardian expressly releases BBPT including but not limited to any of its personnel, owners, employees, contractors, officers, members, agents, representatives or directors from any claims arising from such use or distribution and holds BBPT and its personnel listed herein harmless from any liability arising from the use of their or their child’s picture or voice.

You may revoke this consent at any time by providing written notice to BBPT. Such revocation will apply going forward and will not be retroactive.