Consent for Treatment

Consent for Health Care Services: I authorize consent for medical treatment at Valley Kids Therapy.

Authorization for Release of Information: Valley Kids Therapy may release information from my medical records to any health care provider, any person or organization liable for all or part of my charges, such as my insurance carrier, or any third party payer involved in my care and treatment.

Financial Agreement: I understand that there is no guarantee of payment from any insurance company or other payer. I agree to pay all charges for the services provided by Valley Kids Therapy which are not paid by my health insurance or other payer. All charges are due and payable when I receive the bill. If payment is not made within 90 days from the date the bill was mailed from Valley Kids Therapy, I understand that a delinquent charge of interest rate of 18% may be added to my bill. I agree to pay all reasonable legal expenses necessary for the collection of any debt. I understand that any credit or refund that I may be owed will be forwarded to the address on file with Valley Kids Therapy. I understand that I am responsible for a $25.00 returned check fee in addition to any other associated bank charges. I authorize that payment of any insurance (including auto insurance and healthcare insurance) benefits for health care services or goods may be made directly to Valley Kids Therapy.

Insurance Changes: I accept responsibility to notify Valley Kids Therapy of any changes to my insurance plan, benefits, and/ or coverage. I acknowledge that I am responsible for all charges not covered by my insurance plan.

Pre-authorization Requirements: I accept the responsibility to obtain all referrals or pre-authorizations and to comply with all requirements of any insurance or medical coverage plan upon which I am relying for medical coverage of Valley Kids Therapy charges.

No Show/Cancellation without 48-hour notice: I understand that 48-hour notice is required for canceling an appointment. I understand that after 3 late arrivals or cancelations, my scheduled appointment times will be forfeited to another patient and I will be placed back on the wait list.

Acknowledgement of Participation: I understand that Valley Kids Therapy promotes the advancement of new individuals interested in the practice of physical therapy and I agree to the involvement of students and/or volunteers participating in my child’s treatment at Valley Kids Therapy.

HIPAA/Privacy: I have been offered a copy of Valley Kids Therapy HIPAA Policy. A copy of the HIPAA privacy for Valley Kids is available at any time upon request and available on our internet home page.

COVID-19: I am certifying that I have discussed my care options with my physical therapist, including the option of telehealth physical therapy, and I am choosing to participate with “in clinic” care. By my initials, I attest that I have been made aware of the options available and have determined that in-clinic physical therapy is essential to my best results. I personally and solely accept the associated risk of disease transmission and potential consequences.