Patient Services Acknowledgement & Agreement General Policies and Procedures*

Patient Services Acknowledgement & Agreement General Policies and Procedures*

The undersigned, by providing his/her signature in the space below agrees to accept the services provided by Leaps And Bounds Therapy, LLC in accordance with and pursuant to the terms and conditions set forth herein (the “Agreement”). Client and Scope of Services: Our client (“client”) under this agreement is patient (“Patient”) and you (“You”), the patient’s parent or guardian. Leaps And Bounds Therapy, LLC has been engaged to provide physical therapy services to Patient at Client’s request.

Appointments

Therapy sessions are a total of 60 minutes including 50 minutes of direct intervention and 10 minutes of caregiver consultation on home program. Sessions are completed in the client’s home, classrooms, playground, and/or gym depending on the activity and goal of the session. Caregivers are consulted on a weekly basis depending on the child’s need. Please allow a 10-15 minute grace period for your therapist’s arrival for your scheduled appointment time. Sometimes therapists can be delayed due to traffic, weather, etc.

Communication

Our therapists are available to discuss updates and recommendations by email, phone, and scheduled meetings. If there are any questions or concerns regarding your child’s therapy sessions or home program please do not hesitate to contact your therapist during business hours.

Attendance Expectations:

Our therapists block their time slots especially for your child, and the expectation is that you do whatever it takes to ensure that your child receives consistent therapy. Otherwise, our therapists lose the opportunity to help another child that is in need. It is our belief that only through commitment of consistent therapy, will your child achieve results as quickly as possible.

No shows

If you are not home for your scheduled therapy session and you do not call to cancel in advance, it is considered a ‘no-show’. Therapist will wait 10 minutes from your appointment time but no longer. After Three (3) no shows, the therapist reserves the right to refuse service going forward. (see fee information below for all clients that are not receiving therapy through the early intervention program)

Cancellations

Please contact your therapist by email, voice mail, or text message if an appointment will be cancelled for any valid reason (valid reasons include: illness, doctor’s appointment, pre-planned vacation). Please make sure to inform your therapist AT LEAST: • 12 hours prior to your scheduled therapy session if your child is missing therapy for a planned reason • By 9am THE day of your scheduled therapy session, if your child is sick. Please note that if a child is ill, use your best judgement as to whether or not to cancel his/her therapy session. If a child is easily contagious, then the session should be cancelled. If your child becomes ill within only hours of his/her session, please notify therapist as soon as possible prior to the session. 2 Reviewed January 2021 Frequent cancellations interfere with your child’s progress in therapy. After an excessive number of cancellations (3 in a row; or 4 over the course of 3 months), the therapist reserves the right to refuse services going forward. (see fee information in Financial Policy portion of this “Patient Services Acknowledgement and Agreement Form” for all clients that are not receiving therapy through the early intervention program).

Illness

Fever: Children with a temperature of 100◦ or higher will not receive services. Your child needs to be fever free without medication for 24 hours before they are seen again for therapy. Vomiting: Your child needs to be free of vomiting for 24 hours before being seen again for therapy. Diarrhea: Your child needs to be free of diarrhea symptoms for 24 hours before seen again for therapy. Rash: Children should not be seen for therapy if they have a rash until they receive a note from their physician stating that the rash is not or no longer contagious. Lice: Please let your therapist know if someone in your household has head lice. Therapy will be cancelled until everyone in the home has been treated. Everyone in your household needs to be nit free for 10 days after the last treatment before services begin again. Please be sure to inform your therapist if your child is ill in order to prevent cross-contamination and spread of disease. Diseases and illness not mentioned will be dealt with on a case by case basis. The therapist reserves the right to cancel therapy sessions if she feels that the child needs to rest, recuperate or be seen by a physician/receive a release from their physician before therapy resumes.

Changes in Information

If there are any changes in address or insurance please send the new information as soon as possible to keep Leaps And Bounds Therapy, LLC billing records up to date.

Medical Conditions

Please update the therapist if there are any allergies or medical conditions (injuries, new medications, surgeries) that may impact session performance or ability to participate in therapeutic exercises and activities.

Medical Documents/Communication

Please notify the therapist of doctor or specialist visits that may impact physical therapy sessions or treatment plan. Providing copies of medical information and outside therapy evaluations is appreciated. If communication between therapists or medical providers is requested please provide all necessary contact information.

Electronic Communications and Storage

Unless you advise us to use some other form of communication, Leaps And Bounds Therapy, LLC intends to use state of the art communication devices in the normal course (which may include wired or wireless e-mail, cellular telephones including text messaging, and electronic data/document websites) to communicate with and send or make available documents to you and others. Leaps And Bounds Therapy, LLC shall endeavor to electronically protect all records before transmitting them to protect your privacy; however, we cannot guarantee the security of your email connections or servers. Although there is some security risk with these current technologies, we believe the benefits from using these technologies outweigh the risk of accidental disclosure. By signing this agreement, you consent to our 3 Reviewed January 2021 use of these storage and communication methods and agree to provide us with (and update, as needed) the email contact information that you wish us to use for any electronic correspondence.

Privacy

All information regarding each child and family will be kept confidential. Any release of information must be accompanied with written permission from the child’s parent/legal guardian. Billing and payments are completed through Leaps And Bounds Therapy, LLC with the service of Angelique Robinson; the approved billing service provider for Leaps And Bounds Therapy, LLC.

Financial Policy (Does not apply to Early Intervention clients)

It is your responsibility to confirm your insurance benefits and options and to provide correct and current information regarding your policy to Leaps and Bounds Therapy, LLC. Leaps And Bounds Therapy, LLC will work with your insurance company to obtain precertification for services if required. If insurance approves services and later refuses to cover them, it will be your responsibility to cover the costs and appeal to your insurance company to correct the denials. Pre-authorization may or may not be necessary for physical therapy services. We will provide you with a brief summary of coverage at the initiation of services but please note it is your responsibility to confirm your insurance benefits and understand your policy. Leaps and Bounds Therapy cannot guarantee your coverage, as final determination of claim payment is made by your insurance policy. Your insurance carrier may not approve or reimburse your child’s services for reasons including but not limited to usual and customary rates, benefit exclusions, coverage limits, lack of authorization, or lack of medical necessity. Leaps And Bounds Therapy, LLC is an in-network provider with Blue Cross Blue Shield of Illinois and out-of-network with all other insurance companies. For both in-network and out-of-network clients, private insurance will be billed promptly after services are performed. All invoices for the remaining balance after insurance processes the claims will be sent monthly to you. It will be your responsibility to pay for costs which are not paid by your insurance within 30 days. It will be your responsibility to have any ongoing discussion with your insurance company directly regarding your coverage and any reimbursement issues. Leaps And Bounds Therapy, LLC is not responsible for keeping track of visit limits/caps in services that are specific to your insurance plan. (Please take note of the patient payment responsibility form sent to you for more information on responsibilities). If your insurance plan should ever change the new billing information must be provided immediately in order to avoid the session being billed as an out of pocket service. Any and all fees charged are subject to change at the sole discretion of Leaps And Bounds Therapy, LLC upon prior notice to the undersigned. Any changes to these policies or procedures will be provided to the families.

Payment (Does not apply to Early Intervention clients)

Invoices will be emailed or mailed (your preference) monthly to collect for copays/deductibles/outstanding balances. If after billing insurance, it is determined that payment is owed by the patient, an invoice will be sent with the date of service and amount for each visit. A billing representative will send you an invoice shortly after dates of services. Payment can be sent electronically through your bank, via zelle or by check. At this time, Leaps And Bounds Therapy, LLC is not accepting credit cards.

Late Fee: (Does not apply to Early Intervention clients)

If payment for therapy services, and copays are not paid by the due date indicated on the invoice (30 days) there will be a $25 late fee charged. Checks returned for insufficient funds will incur a $25 processing fee. All outstanding balances remaining unpaid more than 30 days after receipt of an invoice shall accrue interest at a rate equal to 10% per annum of such outstanding balance.

Late Cancellation/Missed “No show” visit Fee: (Does not apply to Early Intervention clients)

For each Late Cancellation (Cancelling AFTER 9am THE day of your session), a $25 fee will be applied to your monthly invoice. For each “No show”, a $50 fee will be applied to your monthly invoice. Please note that if a child is ill, use your best judgement as to whether or not to cancel his/her therapy session. If a child is easily contagious, then the session should be cancelled. If your child becomes ill within only hours of his/her session, please notify therapist as soon as possible prior to the session. It will be determined at the time if the late cancellation fee will be waived at that time.

Right to Refuse Service: (Does not apply to Early Intervention clients)

Leaps And Bounds Therapy, LLC reserves the right to refuse service to any patient on the account of delinquent or unpaid fees for the services performed without any liability or further obligation to the undersigned.

ACKNOWLEDGMENT OF RECEIPT OF PATIENT SERVICES ACKNOWLEDGEMENT AND AGREEMENT FORM

Please review this letter carefully. If the terms contained herein are not consistent with your understanding of our engagement in any respect, or if you have any questions concerning the same, please contact us promptly at (312) 480-7433 or aneri@leapsandboundsIL.com. Absent timely advice from you to the contrary, and, if services are initiated, we will act in reliance upon the understanding that this letter reflects our mutual understanding regarding the terms of our engagement. For avoidance of doubt, however, we ask that you confirm your acceptance of these terms by signing the enclosed copy of this agreement and returning it to us at your earliest convenience.

I, the undersigned, have read and understand the patient services acknowledgement and agreement (the “Agreement”). I specifically agree to be bound by the agreement, and I memorialize my agreement by providing the appropriate signature in the space below:

Self/Parent/Legal Guardian Signature(Required)
Child's Name(Required)
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