New Year Client Renewal And Verification
Date Form Submitted
Name Of Person Completing this form
Cell Phone Number
Relationship To Child
Child's First Name
Child's Last Name
Child's Date Of Birth
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My address has not changed in the last 6 months
Address On File
If your address has changed within the last 6 months, please enter new address below:
My health insurance has not changed in the last 6 months
If your medical insurance policy has changed, please enter the new policy information below:
AUTHORIZATION FOR MEDICAL TREATMENT
Office Practice/Clinic personnel at this facility are hereby authorized to administer any medical, diagnostic, or therapeutic treatment, as may be deemed necessary or advisable. I have the right to consent or refuse consent, to any proposed procedure or therapeutic course, absent emergency, or extraordinary circumstances.
GENERAL CONSENT FOR TREATMENT
I voluntarily consent to receive care for my minor child encompassing Speech Therapy, Occupational Therapy, Physical Therapy, and/or counseling by a Sunshine Center therapy provider as deemed necessary.
DISCLOSURE OF INFORMATION
I understand that medical records and billing information are made and retained by this Office Practice/Clinic and are accessible to office personnel. Office Practice/Clinic personnel may use and disclose medical information for operations, functions and to any other physician or health care personnel involved in my continuum of care. Safeguards are in place to discourage improper access. This Office Practice/Clinic and its medical staff are authorized to disclose all or part of medical records to any insurance carrier, worker's compensation carrier, or self-insured employer group liable for any part of the Office Practice/Clinic's charges and to any health care provider who is or may become involved with my care. Oklahoma law requires that this Office Practice/Clinic advise you that the information authorized for use or disclosure may include information which may indicate the presence of a communicable or non-communicable disease, or related to mental health, or drug, substance, or alcohol abuse. By signing this agreement, you are consenting to such disclosure.
ASSIGNMENT OF INSURANCE BENEFITS
I agree that benefits otherwise payable to the insured are to be made payable to the Tulsa Sunshine Center. Any payment received for this period may be applied to any unpaid bills for which I am liable, subject to the rules of coordination of benefits. Refusal to authorize assignment of benefits will require payment in full by cash, check, or credit card at the time of service.
Please be aware of your coverage benefits for therapy. It is ultimately your responsibility to be informed and to comply with the financial obligations your insurance imposes. A benefits quote is not a guarantee of payment; it may be subject to other plan limitations or exclusions.
RIGHT TO REFUSE
We reserve the right to refuse service for any reason, including but not limited to non-compliance in coming to therapy, acting disrespectfully to our staff and other patients or for unpaid balances. We reserve the right to require payment in full of unpaid balances before scheduling any subsequent appointments or services.
FINANCIAL AGREEMENT AND PAYMENT RESPONSIBILITY
As consideration for the services provided, I (the patient or responsible party) guarantee payment for any amount due for such services provided by this Office Practice/Clinic.
I hereby certify that I have read each of the above statements, understand the contents, and upon request, can be provided a copy of this Patient Agreement. I further certify that I am the patient or duly authorized by the patient to accept the terms of this Patient Agreement. A photocopy of this document has the same effect as the original.
I have been advised that Sunshine Center Pediatric Therapy is able to provide appointment reminders via text. Unsecure text may be intercepted by unauthorized individuals, but I elect to receive these text reminders.
ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES
A complete description of how your medical information will be used and disclosed by this clinic is in our NOTICE OF PRIVACY PRACTICES. I UNDERSTAND THAT A COPY OF THE NOTICE OF PRIVACY PRACTICES IS AVAILABLE TO ME UPON REQUEST.
Patient or Patient's Legal Representative
Relationship to Patient
Please read and initial the Client Attendance/Commitment Statement below:
I understand if:
I arrive late to an appointment, I am NOT guaranteed a full 30-minute, 45-minute, or 1-hour session.
I am more than 15 minutes late for my appointment, my appointment is NOT guaranteed.
I have two (2) consecutive days of no-shows it may result in my child's discharge from therapy.
I cancel with less than 3 hours' notice prior to the appointment, it may be considered a no-show.
my child's 6-week attendance falls below 70%, my child will be taken off the recurring schedule.
I understand a $40 fee will be charged to private insurance and self-pay clients for each no-show appointment.
STREET CROSSING AND OUTDOOR THERAPY RELEASE
I recognize when utilizing Tulsa Sunshine Center's Therapy services, a therapist may choose to use an outdoor activity during the therapy session. This includes, using our playground, gym, sidewalks and or grass area. Your child may need to cross the street (West Detroit Street), walk across the parking lot and or use the sidewalk, accompanied by the therapist, to get to/from the outdoor activity.
I hereby release, discharge, indemnify and hold harmless the Tulsa Sunshine Center along with its officers, and employees for any and all claims, demands, costs, liabilities, settlement agreements, damages, and expenses connected with my child's services at the Tulsa Sunshine Center. I acknowledge that I have read and fully understand the terms and conditions of the street crossing and outdoor therapy release, and that as the legal parent/guardian agree and will comply with the same.
Yes, I give my child's therapist(s) permission to take my child outdoors during the therapy session.
No, I do not give my child's therapist(s) permission to take my child outdoors during the therapy session.
RELEASE OF PROTECTED HEALTH INFORMATION
Information may be released to the following individual(s):
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Sign Below to Confirm Acknowledgement of the above initaled policies:
Parent/Guardian Printed Name
( Draw your Signature below in the box with your finger or mouse )