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Consent and Policy Form
CONSENT TO TREAT:
I (parent or guardian), for the patient named above hereby consent to such medical treatment and diagnostic procedures as beneficial and appropriate for the patient’s condition or illness based on the judgment of the physician(s), to be performed by the health care provider(s). I have had, and will continue to have, an opportunity to discuss treatment options with my health care provider, ask questions regarding such treatment options, and understand the options discussed.
Payment is due in full at the end of each session. You are responsible for any outstanding balances and/or co-pays for services rendered including any portion not covered by your insurance. You authorize charges to your credit card and the charge will appear on your credit card statement. I certify that I am an authorized user of this Credit Card and will not dispute these scheduled transactions; so long as the transactions correspond to the terms indicated in this authorization form.
RELEASE OF MEDICAL INFORMATION:
I hereby authorize Little Champs Therapy & Yoga to release any and all pertinent information contained in my medical records (current and prior) for: Treatment: Includes activities performed by health care practitioners in providing, coordinating, or managing care with third parties and consultations with other health care providers. Payment includes activities involved in receiving payment for services rendered and any review of care for medical necessity, justification of charges, and pre-authorizations.
NOTIFICATION OF INSURANCE COVERAGE:
I hereby agree to notify Little Champs Therapy & Yoga) of any change in insurance coverage including changing insurance provider, adding or removing insurance company, coordination of benefits, notifications of eligibility or ineligibility to current insurance provider, or any changes that may affect. Failure to notify of such change may incur financial liability. PAYMENTS: Payment is due in full at the end of each session. You are responsible for any outstanding balances and/or co-pays for services rendered including any portion not covered by your insurance. You authorize charges to your credit card and the charge will appear on your credit card statement. I certify that I am an authorized user of this Credit Card and will not dispute these scheduled transactions; so long as the transactions correspond to the terms indicated in this authorization form.
APPOINTMENT CANCELLATION POLICY:
Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in your therapist's that could have been filled by another patient. As such, we require 24 hours notice for any cancellations or changes to your appointment. Patients who provide less than 24 hours notice, or miss their appointment, will be charged a cancellation fee. Unpredictable incidents and emergencies can dictate a missed appointment (no-show) or same day cancellation. If you have one of these rare incidents, we will be glad to work with you to reschedule the appointment without a service charge.
Courteous fee wavier for first occurrence. If you consistently miss your scheduled appointments four or more times, this may result in dismissal from our practice. Our goal is to provide your child with timely access.
$25 fee for second occurrence within 12-month period. Medicaid clients will never get charged this amount
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District of Columbia
Armed Forces Americas
Armed Forces Europe
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Credit Card Number
Enter the MM/YY
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Photo Consent (check boxes):
We take and use photographs and/or digital images of child for use in news release and/or educational materials as follows: printed publications or materials, electronic publications, or website. As such, child’s first name and identity may be revealed in descriptive text or commentary in connect with the image(s). These images are used by the clinic without compensation. All prints, and/or digital reproductions shall be the property of Clinic and never sold to a third party.
I DO hereby grant permission
I DO NOT hereby grant permission
Date of Birth
Date Format: MM slash DD slash YYYY