Combined Consent to Treatment

Consent that all information, including client assessment, treatment notes, etc. are treated with strict confidentiality and no information, either verbal or written, will be shared without the written consent of legal guardian (if client is under age of 18). I understand that individuals responsible for care through Carrousel Therapy Center will need to have access to confidential information for the purpose of assessment and treatment coordination. 1. It is the patient/parents(s)/guardian responsibility to inform “CTCC” of any and all changes in insurance information, including group policy number, identification number, phone numbers, addresses, etc. as soon as possible. Failure to do this could result in total patient responsibility for charges incurred. 2. Cancellation Policy – We are committed to providing quality consistent services to our clients. Therapy will be most beneficial to your child with consistent attendance. It is also important that you arrive on time so that your child can benefit from a full session. Routine tardiness may result in billing that time directly to you. We understand that there will be unavoidable circumstances that may come up. In order for us to plan appropriately for staff, we require that parents call to cancel their appointment for illness or an unavoidable conflict as soon as possible. We reserve the right to charge a fee of $50.00 for missed unexcused absences (PLEASE CALL 24 HOURS IN ADVANCE TO CANCEL OR RESCHEDULE YOUR APPOINTMENT), and $25.00 for arriving 15 or more minutes late. Termination of services may occur following three sessions that were not cancelled ahead of time or following routine/regular cancellations. When possible, we will try to reschedule your appointment that week. There are many families that are waiting for services. We appreciate your cooperation with this. 3. For your convenience, “CTCC” allows parents/legal guardians or caregiver to leave the premises during their child’s appointment. However, it is very important to be back on the premises 10 minutes before the patient’s appointment is scheduled to end so the therapist can discuss treatment with the parent/legal guardian or caregiver. If “CTCC” notices chronic tardiness in picking up children, we will begin asking the parent/legal guardian or caregiver to stay during the patient’s treatment. “Therapy” must have a cell phone number to reach you before leaving. By signing below, the parent also agrees to waive any and all responsibility that “Therapy” may have in ensuring the safety of your child after the therapy session time has finished. We are not a babysitting service and cannot be held responsible for your child’s safety after his or her therapy session has finished. 4. Additionally, “CTCC” realizes the parent/legal guardian or caregiver’s time is important, and it is our sincere intention to honor all appointment times. On occasion, a delay or emergency will occur. For this reason, we may need to delay or reschedule the patient’s appointment. If this occurs, notification by text, phone call or email. will be given as early as possible. To expedite this process, we ask the parent/legal guardian/caregiver to provide us with a daytime telephone number with text capability, and e-mail for notification purposes. 5. Out of pocket policy: Insurance policies are contracts made between the patient and the insurance company. When insurance does not provide payment of therapy costs, payment of the bill is your responsibility. If for any reason treatment is denied by your insurance, we will charge for the usual and customary amount paid by your insurance company. For your benefit, and to insure the highest level of coverage from your insurance company, we choose to participate in most insurance plans, which results in lower payments to the provider but lower costs to the patient. Both private insurers and the Federal Government prohibit waiving and/or reducing the co-payments. Due to binding contracts with each insurance company and industry wide standard ethics, we are required to collect all co-payments and deductibles that are due by your specific policy. We are obligated to be in compliance with these standards. In case of hardships: The parent/legal guardian must provide written notification to “Therapy” detailing the circumstances warranting a need for a reduced fee. Completion of a personal financial statement form is required to be completed for our consideration. If granted, reduced fees are provided for a period of six months. Prior to the end of the six months, if circumstances have not changed, parents may request an extension in writing. Waiver: Your child or you, is receiving Occupational, Physical, and or Speech Therapy services from board certified Therapists, and Primary Care or Psychiatric Services, Psychosocial Rehabilitation, or Targeted Case Management, The plan of care is a collaboration of the Therapist and the family. To ensure that you or your child will improve, all recommendations need to be followed as given. Even if this occurs, every child responds in their own way. We cannot guarantee that the Parents/Caregivers predetermined outcome for their child will be achieved. By signing below, you agree to these statements and conditions presented above.