Client Policies Form

CLIENT POLICIES

Revised October 2019

Welcome to Center for Developing Kids, Inc. (CDK). We are pleased to work with your child and family. Our mission is to provide children with the opportunity to attain their highest developmental potential using a collaborative and caring, multi-disciplinary team approach. We strive to provide quality therapy services, which do not separate the child from the context of the family or typical everyday environments, and ultimately enable the child to engage in activities that give meaning to his/her/their life. In order to serve you and your child effectively under a mutual understanding of our guidelines, please carefully read the following policies and sign at the bottom of the page.

PRIOR TO SERVICES

  1. All forms must be submitted online. A credit card must be left on file to pay for applicable deductibles, copayments, and fees.

  2. Unless paying privately, authorizations must be in place prior to receiving services.

  3. If using insurance, it is recommended that I check with the insurance company to ensure that the requested services are a covered benefit per the relevant policy. The CDK front office will also contact the insurance company once I have provided my information. If the front office indicates that a prescription is required, I must obtain this from my child's doctor and provide it to the front office prior to the appointment.

  4. Once an evaluation is completed, if treatment is recommended, CDK will attempt to place my child on the schedule. However, CDK cannot guarantee immediate availability.

CONDITIONS OF TREATMENT

  1. CONSENT TO TREATMENT/ASSESSMENT
    I hereby consent to the administration and performance of all evaluation procedures and treatments within the realm of current standards of practice, which in the judgement of my child’s therapist may be considered necessary or advisable.

  2. CONSENT TO USE OF THERAPEUTIC EQUIPMENT
    I, on my behalf and on behalf of my child, fully understand that there is a risk of personal injury to my child in participating in play-based activities and other physically active games through the programs provided by CDK. I am aware that my child is engaging in physically active games and/or therapeutic activities, which could result in injury. I am voluntarily allowing my child to participate in these activities and assume all risks of injury that may result. I personally, and on behalf of my child, agree to hold no individual or corporation responsible or liable for any injuries and associated costs that my child receives on account of these activities, including but not limited to CDK, or it’s officers, employees, agents, aides, therapists, assistants, successors, instructors, insurers, or assigns (hereinafter “Releases”). I further agree to waive any claims or causes of action against and to hold harmless said Releases for any injuries or damages which my child suffers or might suffer as a result of the conduct of any person during or in conjunction with said physically active games or therapeutic play-based activities.

  3. CONSENT TO PHOTOGRAPHY
    I hereby agree to allow CDK to take and/or use any pictures/tapes/videos/films of me or my child with my full knowledge and consent as a client of CDK. This visual record may be used for teaching and training activities and/or as a part of my child’s medical/developmental record as CDK may deem proper. My child’s identity will not be made public without my expressed permission for a specific occasion or purpose. Any use of my child for public relations will also require my specific permission and knowledge.

  4. CONSENT FOR EMERGENCY TREATMENT
    As the authorized representative, I hereby give consent for CDK, to obtain all emergency medical or dental care prescribed by a duly licensed physician (M.D), osteopath (D.O.), or dentist (D.D.S.) for my child. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my child. My signature at the bottom of this form testifies that I am the authorized representative of the child named on this document. Further, I will be responsible for the charges for any medical or dental treatment or hospitalization rendered by reason of this authorization.

  5. ILLNESS
    I understand that children must not attend services if they've had a fever, had diarrhea, or started antibiotics in the the 24 hours prior to a session, have an unexplained rash, are coughing frequently, have yellow or green nasal discharge, or are behaving as though they are not well (e.g. lethargic, fussy). I understand that on specific occasions, caregivers may need to provide a doctor's note for my child to participate in services.

  6. RELEASE OF INFORMATION
    I hereby agree that CDK may release information, either written or verbal, regarding my child’s medical status and progress to professionals who have been or are currently involved in the treatment of my child. I hereby agree that, to the extent necessary to determine eligibility for services and to obtain reimbursement, CDK may disclose portions of my child’s records to funding agencies such as health care insurance plans, school districts, and regional centers.

  7. ATTENDENCE
    It is extremely important to consistently attend appointments on time and avoid unnecessary cancellations. I understand that there are fees for late cancellations of clinic and home-based sessions, those cancelled less than 24 hours prior to the appointment time. These fees start with the 4th occurrence ($50) and increase with the 7th occurrence ($75). There are fees for “no shows,” sessions that are not attended and not cancelled in advance of the session start time ($165). These fees are subject to change at any time. At least 75% of sessions must be attended on time in order to maintain a standing appointment time. If 25% or more appointments are missed in a 3 month period, my child’s therapy may be terminated.

  8. CANCELLATIONS
    All cancellations must be sent to cancel@centerfordevelopingkids.com.

  9. VACATIONS AND EXTENDED ABSENCES
    If two consecutive treatment sessions are cancelled or missed, for example due to vacations or serious illness, that appointment time may not be reserved.

  10. FINANCIAL AGREEMENT
    I hereby agree that in consideration for services to be rendered by CDK, I shall make prompt payments to the account of CDK as bills are presented. I agree to pay interest at the legal rate should the account become delinquent, and if it becomes necessary for the account to be referred to an attorney for collection, I shall pay the actual attorney’s fees and collection expenses.

  11. THIRD-PARTY FUNDERS
    An explanation of charges will accompany my payment receipt and invoice. It is my responsibility to notify the front office at CDK if there are changes to my child’s insurance. In the event that my insurance or other funding agency does not pay within 90 days for rendered services, regardless of the reason, I am responsible for payment.

  12. PARENT PRESENCE
    Therapy sessions are provided individually or in group settings depending on the service/clinical recommendation. If my child is receiving therapy in a home or community, a caregiver must be present at all times. If my child is receiving therapy in the clinic, caregivers may remain in the waiting room or participate in the session as long as they are directly with their child and therapist. I understand that observing from afar, using cell phones, reading, or using a computer is not permitted within the clinic treatment space.

  13. SIBLINGS AND ACCOMPANYING CHILDREN
    I understand that caregivers are responsible for supervising all children brought to the CDK waiting room, and that only children under direct care of a CDK therapist may use equipment and toys in the treatment space.

  14. DROP-OFF AND PICKUP
    I understand that children must be monitored in the waiting room and cannot be dropped off unattended. If I or another caregiver is leaving the clinic, I/he/she/they must provide a phone number at the front desk in case of an illness or emergency. I understand that caregivers are expected to arrive at the clinic 5 minutes prior to the session ending for a prompt pick up. There is a flat fee of $10 plus $2/minute late fee for pickups after the end of a session.

  15. END OF SESSIONS
    I understand that discussions with caregivers about activities and goal progress are part of intervention. Therapists and children may arrive in the waiting room prior to the session ending to account for this.

  16. EMERGENCY CONTACTS
    I understand that CDK may contact or release my child to emergency contacts I list on this form if a primary guardian is not available at the end of a session or program, or in the case of an emergency.

  17. EMERGENCY EVENT
    Following an emergency event, assuming conditions are deemed safe, children will be released to their guardians. If it is not feasible for a guardian to pick up a child, employees will take children to a verified safe location determined by the American Red Cross and/or communicated by the National Emergency Broadcast System. In an immediate building evacuation, employees and children will be instructed to assemble at the nearby Lamanda Park Branch Library.

  18. RE-EVALUATIONS
    Yearly evaluations are conducted for private pay clients per standard best practice guidelines. Evaluations for services through a funding agency are conducted according to the agency’s guidelines.

  19. COVERAGE
    At times, therapists will take time for meetings, continuing education, vacation, or sick time. When this impacts scheduled appointments, CDK will provide coverage whenever possible.

  20. INTERNSHIP PROGRAM
    CDK collaborates with accredited universities throughout the country by accepting occupational, physical, and speech therapy interns as part of fieldwork/internship programs. I understand that when my child’s therapist is a clinical instructor, it is likely that an intern will participate in all aspects of my child’s treatment with supervision from their clinical instructor(s).

  21. NON-DISCRIMINATION
    CDK strives to maintain an inclusive environment without discriminating on the basis of race, religion, sex, national origin, sexual orientation, age, or disability. I understand that I and other guardians of my child are expected to participate in this endeavor and show mutual respect for members of our community.


HIPAA. NOTICE OF PRIVACY PRACTICES

This section describes how medical information about your child may be used and disclosed, and how you can get access to this information. Please review it carefully.

USES AND DISCLOSURES*

  1. We will use your child’s protected health information (PHI) for the purposes of treatment, payment and health care operations.

  2. Treatment includes the disclosure of health information to other providers who have referred your child for services or are involved in his/her care. This may include doctors, nurses, other occupational therapists, physical therapists, or speech therapists, psychologists, regional center service coordinators, or schools.

  3. Payment includes the disclosure of health information to your insurance company or to a school district or regional center so payment can be obtained for services rendered.

  4. Health Care operations include the utilization of your child’s records to monitor the quality of care being provided at our facility.

  5. Our practice may use your child’s PHI to request information about your child or to send you information regarding other health or therapy-related services.

  6. The federal health information policy regulations either permit or require us to use or disclose your child’s PHI in the following ways: we may share some of your child’s PHI with a family member or friend involved in your child’s care if you do not object, or we may use your child’s PHI in an emergency situation when you may not be able to express your wishes for your child. We may also disclose your child’s PHI when we are required to do so by law, for example, by court order or subpoena. Disclosures to health oversight agencies are sometimes required by law to report certain diseases or adverse drug reactions. We may use and disclose health information about your child to avert a serious threat to your child’s health or safety, or to the health or safety of the public or others. Your authorization is required before your child’s PHI may be used or disclosed by us for any other purposes.

* Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permissions.

PRIVACY RIGHTS**

  1. RESTRICTIONS
    You have the right to request restrictions on how your child’s PHI is used, however, we are not required to agree with your request. If we do agree, we must abide by your request.

  2. CONFIDENTIAL COMMUNICATIONS
    You have the right to request in writing the way we communicate with you about medical matters in a certain way or at a certain location.

  3. ACCESS TO PHI
    You have the right to request a copy of your child’s medical record. This request must be in writing and we may charge a fee to cover the copying and mailing.

  4. AMENDMENTS
    If you feel that medical information we have about you or your child is incomplete or inaccurate, you may request an amendment in writing. Your request may be denied if you do not include a reason to support the request.

  5. RESTRICTIONS
    You have the right to request a restriction or limitation on the medical information we use or disclose about your child for treatment, payment, or health care operations.

  6. ACCOUNTING OF DISCLOSURES
    You have the right to request in writing, a list of accounting for any disclosures of your child’s medical information we have made, except for uses and disclosures of treatment, payment, and health care operations, as previously described.

  7. PAPER COPY
    You have the right to a paper copy of this notice at any time.

** If you feel that your privacy rights have been violated, you have the right to make a complaint to us in writing without fear of retaliation. Your complaint should contain enough specific information so that we may adequately investigate and respond to your concerns. If you are not satisfied with our response, you may complain directly to the Secretary of Health and Human Services.

I have reviewed, understand, and agree to the above policies and Notice of Privacy Practices.

Please sign below.