Child Occupational Therapy - Clinic Policies/Intake Questionnaire/Wellness Policy/HIPAA
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Clinic Policies
Please read the following policies. Print copy of this document for your records.
For each of the sections below, please type your initials in the field below the text to acknowledge the content.
Scheduling/Participation *
In order for your child to reach his/her established treatment goals, it is imperative that scheduled therapy sessions be consistently attended. We are aware that unanticipated emergencies (e.g. illness, vacations) take place. We require that your children to maintain a 75% attendance rate at his/her regularly scheduled time slot.  If appointments are not attended on a consistent basis, your child may be moved to a different treatment time slot.
Late Arrival *
We attempt to start all therapy sessions on time. Therefore, we ask that your child is punctual for his/her session. If your child arrives late for his/her appointment that time will be deducted from the overall scheduled time and will subsequently reduce the amount of direct treatment time that your child will receive during that therapy session. If untimely attendance occurs on a consistent basis, your child may be moved to a different treatment time slot.
Late Cancellations *
We request 24 hours’ notice for a cancelled appointment in order for our therapists to have the opportunity to adjust their schedule accordingly. An appointment that is not cancelled at least 24 hours prior to the scheduled appointment time is considered a Less Than 24 Hour Cancellation and you will be charged full fee for the scheduled therapy session. Certainly, we understand that there are exceptions to this policy, such as sick children and family emergencies, which are not possible to control. Please note that it is your responsibility to contact our office as soon as possible to eliminate any extra fees. You may also contact our office at the number above and leave a message after hours.
No Shows *
Appointments that are not cancelled are considered a No Show. No Show appointments are charged the full rate of the scheduled therapy session.
Late Patient Pick-Up *
The late pick-up fee is $35.00 for every 15 minutes. If you leave the clinic during your child's session, please return at least 10 minutes before the therapy session is scheduled to conclude. If an emergency occurs, please contact the office as soon as possible so that we can make accommodations for your child.
Notice to Discontinue Treatment *
If you choose to discontinue your child's therapy services, you must provide 30 days notice prior. Cancellation of therapy services must be received in writing (verbal cancellations will not be accepted). If the proper notice is not provided, you will be held financially accountable for the number of appointments that would be scheduled during this 30 day period.  The therapy services will be charged at the full rate if not covered by your insurance carrier.
HOLD Policy *
It is for the benefit of your child that he/she receive consistent treatment and are present for all scheduled therapy sessions. We understand that certain personal situations may require your child to have a short absence from therapy. We are able to put your child on HOLD for a maximum of 30 days. All HOLD requests must be received in writing (verbal requests will not be accepted). If your child has not reengaged in treatment during this time frame, he/she will then be discharged. In order to reengage in treatment after this 30 day period, he/she will have to complete a new intake assessment.
Feeding Treatment *
You will be responsible for providing the correct food items that the therapist suggests for treatment sessions. If you request that we provide food for your child's therapy sessions, there will be a $25.00 monthly fee to cover the expenses.
Clinic and Waiting Room Etiquette
The care and safety of children and/or siblings that accompany you to your child's therapy sessions are your responsibility. In addition, your child's safety is your responsibility when not accompanied by his/her therapist. For their protection, children are not allowed in other areas of the clinic unless escorted by a parent or guardian. We ask that you please monitor your child in the waiting room and respect the property of NHWS and the other families in the reception area.

Supervising Children *
We make every effort to keep our waiting room clean and tidy. If you bring snacks and/or drinks into the waiting room, please keep the area clean of any spills. We greatly appreciate the use of lidded cups. Please supervise your children in the restroom.
Patient Care *
NHWS provides occupational therapy services and materials in compliance with the orders of your child's attending physician. Administration of treatments will be delivered as ordered by said physician. (1) Consent to treatment: You acknowledge that your child is under the medical treatment and care of said attending physician, and that NHWS renders its services to your child under the general and specific instructions of said physician. You recognizes that your child's physician is an independent agent and is not an employee or contractor of NHWS. (2)Restrictions and liabilities: NHWS shall incur no liability for injuries of any kind suffered by your child while under care; should treatment be discontinued before the attending physician has so ordered, you are agreeing to assume all responsibility for all results which follow.
Payments *
Payment is due at the time services are rendered. The individual who brings the patient to therapy is responsible for payment of the therapy session. Please make all checks payable to New Horizons Wellness Services, LLC. Please note that there is a $40.00 charge for all returned checks. The credit card receipt provided at the time of services is your receipt. Statements are provided upon request only.
Insurance Billing
You are required to pay your annual out-of-network or in-network deductible at the beginning of your plan’s calendar year. After your out-of-network or in-network deductible has been satisfied, you are responsible for the co-pay or co-insurance amount set by your insurance carrier. Any non-covered services are your financial responsibility.

Co-payments, co-insurance, non-covered services and/or deductibles are your responsibility and are due at the time services are rendered. In the event that payment for a performed service is denied by your insurance carrier, it is your responsibility to pursue action with them, as the policy is a legal contract between you and your insurance company.

We do not bill secondary insurance *
Visit Limits *
Visit limits are set by your insurance carrier. If your insurance policy has visit caps or limited visits, it is your responsibility to track these visits as they occur. If you have participated in any therapy services with another provider during the insurance year, then you will need to include those visits. This is especially important if additional services such as occupational therapy, physical therapy, etc. are also being received.
Patient Release for Interns and Volunteers
NHWS is a teaching clinic, so on occasion student interns from various colleges may accompany your child’s therapist, observe treatments, and have sight of their notes. A background check through each respective institution is conducted for each student intern. NHWS periodically allows volunteers to assist in the clinic. They will be in the treatment area with your child under the supervision of your child’s therapist. All volunteers has received HIPAA privacy instructions. Volunteers are not employees of NHWS and cannot assist you with billing, scheduling, medical or insurance information.

Signature *
I understand that my child’s treatment, testing, evaluations, daily and progress notes, and discharge summaries may be seen by student interns in training and volunteers. I also understand that the student interns and/or volunteers may be involved in the treatment of my child.
Contacting Your Therapist *
Please note that telephone calls are answered between 9:00 am - Noon and 1:00 - 5:00 pm, Monday through Friday. Messages may be left on our voice mail system. We will make every effort to return your call on the same day you make it, or at least within 24 hours, with the exception of weekends and holidays. Electronic communication, such as emails, presents a potential risk to your child’s confidentiality.  While you may find this a convenient way to communicate you must be aware of the risks. We will respond should you choose to email us regarding non-clinical issues such as appointment scheduling. Please note we will not engage in "therapy" nor respond to casual "chats" via email. Information exchanged by fax/email will become a part of your child’s clinical records.
Joint Custody Payment Policy *
NHWS cannot divide credit card payments for children of divorced parents. NHWS’s policy requires that the parent or guardian who brings the child in for services be financially responsible for payment of treatment services unless other arrangements are made in advance through the business office. Parents may pay separately by check but payment must be made in full. For credit card payments, only the signatures of the cardholders present at the appointment are allowed. There are no exceptions to this policy.
Your signature below validates your initials on each of the clinic policies described above.

Electronic Signature Agreement:
By selecting the "Send" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "Send" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and New Horizons Wellness Services, LLC. You are also confirming that you are the responsible party authorized to enter into this Agreement.

Patient’s Name *
Parent/Guardian Name (print) *
Parent /Guardian Signature *
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