Patient Orientation Handbook

STATEMENT OF CONFIDENTIALITY This booklet may contain protected health information. Persons other than you and your health care providers must have your permission to view this booklet.

Reach Pediatric Therapy Center 9220 Kirby Dr., Ste. 1000 Houston, TX 77054 (713) 383-9700

PATIENT ORIENTATION HANDBOOK

WELCOME AND PHILOSOPHY

What to Expect from Therapy

I. Overview

 Criteria for Admission  Services  Hours of Operation  Charges  Medical Records  Patient Satisfaction  Discharges, Transfers, Referrals

II. Rights and Responsibilities

 You Have The Right To  Your Responsibilities  Grievance Procedure  Privacy and Security  Financial Information  Notice of Privacy Practices

III. Abuse, Neglect and Exploitation Policy

IV. Employee Background Checks

V. Infection Control

VI. Consent for Treatment, Assignment of Benefits and other admit paperwork

WELCOME AND PHILOSOPHY

Reach Pediatric Therapy Center extends a warm welcome to you, our client, and to your family and friends. Your medical treatment, safety and happiness are most important to us. We will do our best to answer any questions you may have concerning our services.

Reach Pediatric Therapy Center provides this Patient Handbook as a brief overview of our services and policies. This book provides general information and we encourage you to direct any concerns, questions or comments to our office so we can address them promptly. It also explains your rights and responsibilities as well as how we protect your child’s medical information. In addition, you may be asked to complete a questionnaire. We value your input and continually strive to improve our services.

Thank you for entrusting us with your child’s care.

Sincerely,

The Therapists and Staff of Reach Pediatric Therapy Center

This agency is in compliance with Title VI of the Civil Rights Act of 1964, with section 504 of the Rehabilitation Act of 1973 and with the Age Discrimination Act of 1975. We do not discriminate on the basis of race, color, religion, sex, sexual orientation, national origin, age or disability with regard to admission, access to treatment or employment. We will make every effort to comply with these and similar statutes. What to expect from therapy

We are here to serve your child’s therapy needs and so glad you chose Reach Therapy Center! Reach strives to bring excellence through education, training and mentoring of our staff to maximize the outcomes in therapy. As the parent, guardian or family member, you are the key to your child’s success in therapy. Here are some items that will be helpful to know:  After we evaluate your child, it takes time to get doctors orders and insurance authorization. We do our best to keep you informed, but if you have questions please contact our intake or authorizations departments.

 Please have your child prepared for therapy when they get here. This means being rested, bathroom needs cared for, and a snack or meal if necessary.

 Being on time and consistent with attendance is VERY IMPORTANT for your child to make progress in therapy and for compliance with your child’s plan of care. If attendance is not consistent, therapy will be less effective, and you risk losing your therapy spot to another patient. We know this is a commitment. If you are unable to commit to the time a treatment, frequency of your visits, or the location of the therapy please talk with our staff about your options.

 We strive to start your therapy session on time. Please arrive on time for your child’s therapy sessions. If you are later than 15-20 minutes of your session we may not be able to see your child.

 Because we want your child to gain the most they can from therapy, and because we want to remain client with the physician’s ordered plan of care, any therapy sessions missed will be rescheduled.

 Your therapist should give you a home program of activities or items to work on. If you are unsure of what you should be working on please ask.

 Parents are welcome to come into therapy with their children. Sometimes this is beneficial and other times children do not work as well with family/friends present. Discuss this with your therapist to determine the best choice for your child.

 Frequency, duration and co-treat recommendations will be explained to you by our therapists after thorough evaluation of your child’s skills.

 Please remember that treatment areas are group areas for medical care and try to provide as much privacy for other children by staying with your child and only watching their treatment.

 Please do not allow your other children to divert the therapist’s attention or play on the therapy equipment. They will not be able to give 100% of their attention to your child receiving therapy.

 You are a partner in your child’s care. Feel free to ask why we do a certain thing, what we are looking for from your child, or what goals we are working on.  If your insurance or payment goes “on hold” we will not be able to hold your therapy spot. We will be happy to work to reschedule you when your payment method is viable. Please make sure to complete and return any Medicaid paperwork mailed to you to ensure continued coverage.

 We try to provide the best therapists available. Every therapist at Reach is licensed, qualified, trained, and supervised. You may be expected to see a “substitute” therapist or change therapists at Reach’s discretion. If any problems arise these can be discussed with a supervisor.

 Please keep food and drinks in the waiting room.

 For their safety and the safety of others, please monitor your children in the waiting room area.

If there are every any questions you need answered, please contact your child’s therapist or their supervisor. We will gladly assist you!

I. OVERVIEW

This book contains general information regarding your rights and responsibilities as a patient. As state and federal regulations change, there may be additions or changes to this book as necessary. CRITERIA FOR ADMISSION Admission to Reach Pediatric Therapy Center can only be made upon the orders of a physician based upon the identified medical needs of the patient, and the type of services required that we can provide or through coordination with other organizations. If we cannot meet your needs, we will not admit you or will not continue to provide services to you.

SERVICES We offer clinic based Physical, Occupational, and Speech evaluations, treatment, and screening services for children with suspected or diagnosed delays and disabilities. Available services include:  NDT certified therapists  Sensory Integration Therapy  Bilingual therapists on staff  Articulation/Language Therapy  Assistive Technology  Parent resource library  Aquatic Therapy  Feeding specialists HOURS OF OPERATION Office Hours: Our hours are Monday through Thursday from 8:30 a.m. to 6:00 p.m. central time, except during agency holidays. Friday hours are by appointment only. After Hours Coverage: For your convenience we have available 24hr. answering service for schedule changes and cancellations. Please call 713-383-9700 to request schedule changes or to cancel or reschedule an appointment. We ask that when possible to call at least 24 hrs. in advance to cancel an appointment. CHARGES We accept payment for service from Medicaid, Private Insurance or Private Pay. Some insurers may limit the number and type of services that they will pay for and may require pre-certification. We will inform you, your family, caregiver or guardian of the approximate maximum dollar amount, in writing, for any amount for which the patient may be responsible.

If you change insurance (including enrolling in Medicaid or an HMO) during the course of services, you are obligated to inform Reach Pediatric Therapy Center prior to the last date of coverage. Failure to inform us timely will result in your obligation to pay for services.

MEDICAL RECORDS Your medical record is maintained by our staff to document physician orders, delivery, and billing records. Your records are kept strictly confidential by our staff and are protected against loss, destruction, tampering or unauthorized use. Our Notice of Privacy Practices describes how your protected health information may be used by us or disclosed to others, as well as how you may have access to this information.

PATIENT SATISFACTION You, our customer, are very important to us. Please ask questions if something is unclear regarding our services, the care you receive, or fail to receive. At intervals, our agency sends out Patient Satisfaction Surveys, or you may be called by a staff member to complete these. Your answers help us to improve our services and ensure that we meet your needs and expectations. If you receive a Patient Satisfaction Survey, please complete the survey and return it in the postage paid envelope. Patient Satisfaction Surveys are also available upon request.

DISCHARGE, TRANSFER AND REFERRAL Discharging a patient to the care of self, family, institutional care settings or any other setting shall be a coordinated effort involving all members of the health care team. Except in the situation listed below, it is the policy of this agency to notify the patient, family, legal representative and/or the patient’s attending physician of the intent to discharge the patient with a written notice. If we are notify you verbally of discharge, a letter will be mailed to your home address on file.

The transfer or discharge will be discussed with you. If your child is transitioning to another organization, we will provide them with information necessary for your continued care. All transfers or discharges will be documented in the patient chart, and a copy sent to the physician. When a discharge occurs you will receive any instructions needed for ongoing care or treatment from your therapist or staff.

Discharge, transfer or referral from this agency may result from several types of situation including the following:  Treatment goals are achieved;  The level of care your child need changes;  Agency resources are no longer adequate to meet your child’s needs;  Situations may develop affecting your child’s welfare or the safety of our staff;  Failure to follow the attending physician’s orders; including poor attendance  Nonpayment of charges;  Failure to meet insurance coverage guidelines, and refusal to self pay. A transfer or discharge may occur without written advance notice:  Upon the client’s representatives request;  If the client’s medical needs require a transfer, such as a medical emergency;  In the event of a natural disaster when the client’s health and safety are at risk;  For the protection of staff or a client after the agency has made a documented reasonable effect to notify the client’s family and physician, and appropriate state or local authorities of the agency’s concerns for staff or client and in accordance with agency policy;  According to physician orders; or  If the client’s family fails to pay for services, except as prohibited by federal law.

II. RIGHTS AND RESPONSIBLITIES You have the right to:  Have your communication needs met – to receive information in a form and / or language that you can understand;  Ethical standards and conduct – to have a relationship with our staff that is based on honesty and ethical standards of conduct. We will inform you any business relationship we have if we refer you to another organization, service, individual or other reciprocal relationship;  Be free from abuse – to be free from mental and physical abuse;  Lodge complaints – to have your complaints heard, reviewed and if possible resolved. Our complaint resolution process regarding services or a lack of respect for property is explained. You also have the right to know about the results of such complaints. Contact the Outpatient Clinic Director or Administrator at (713) 383-9700.  No reprisals – to voice grievances without fear of discrimination or reprisal for having done so.

Your Responsibilities:  Advise us of problems – to advise us of any problems or dissatisfaction with the services provided by Reach Pediatric Therapy Center.  Show respect and consideration – for agency staff and equipment;  Keep us informed – of any changes regarding your insurance eligibility; and  Meet your financial obligations – and responsibilities agreed upon with the agency.  Follow medical recommendations - in alignment with physician orders directing therapy.

GRIEVANCE PROCEDURE Our goal is to assist your child in achieving his/her maximum level of functioning and therapeutic progress. We are committed to assuring that your rights are protected. If you feel that our staff has failed to follow our policies or has in any way denied you your rights, please follow these steps without fear of discrimination or reprisal. 1. Please contact one of our department supervisors or directors. They are available at our main office number of (713) 383-9700. 2. Notify the Outpatient Clinic Director or Administrator at (713) 383-9700. We will investigate all complaints within 48 hour and a written resolution will be on file within 30 days. 3. We ask you give us every opportunity to resolve any grievances you may have. After our efforts, if you still have a concern, you may also call HHSC at 1-800-252-8236.

PRIVACY AND SECURITY You have the right to:  PRIVACY AND SECURITY – respect for your personal privacy and security during your therapy sessions and time in our clinic.  CONFIDENTIALITY – confidentiality of written, verbal and electronic information including your medical records, information about your health, social and financial circumstances.  RELEASE OF INFORMATION - request us to release information written about you only as required by law or your written authorization, and to be informed of procedures for disclosure. Our Notice of Privacy Practices describes your right in detail.

FINANCIAL INFORMATION You have the right to:  Insurance information – to be informed of the extent to which payment may be expected from Medicare, Medicaid, or any other payer known to us;  Know of charges not covered – to be informed verbally and in writing at the time of services begin, the approximate maximum dollar amount, if any, of services to be borne by the patient.  Receive information with 30 days - to receive this information orally and in writing, before services are initiated and within 30 working days of the date the agency becomes aware of any changes in charges; and  Have access to all bills – to have access, upon request, to all bills for services you have received regardless of whether the bills are paid out-of –pocket or by another party

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY

Reach Pediatric Therapy Center is required by law to maintain the privacy of protected health information and to provide you adequate notice of your rights and our legal duties and privacy practices with respect to the uses and disclosures of protected health information. [445 CFR § 165.520] We will use or disclose protected health information in a manner that is consistent with this notice.

Reach Pediatric Therapy Center maintains a record (paper/electronic file) of the information we receive and collect about your child and of the care we provide your child. This record includes physicians’ orders, assessments, medication lists, clinical progress notes and billing information. As required by law, Reach Pediatric Therapy Center maintains policies and procedures about our work practices: including how we provide and coordinate care provided to our patients. These policies and procedures include how we create, maintain and protect medical records, access medical records and information about our patients, how we maintain the confidentiality of all information related to our patients’, security of the building and electronic files, and how we educated staff on privacy of patient information.

Patient information must be used and disclosed to other parties for purposes of treatment, payment and health care operations. Examples of information that must be disclosed:

 TREATMENT: Providing, coordinating or managing health care and related services, consultation between health care providers relating to a patient or referral of a patient for health care from one provider to another. For example, we meet on a regular basis to discuss how to coordinate care to patients and schedule visits.  PAYMENT: Billing and collecting for services provided, determining plan eligibility and coverage, utilization review (UR), pre-certification, medical necessity review. For example, occasionally an insurance company requests a copy of the medical record be sent to them for review prior to paying the bill.  HEALTH CARE OPERATIONS: General agency administrative and business functions, quality assurance/improvement activities; medical review; auditing functions; developing clinical guidelines; determining the competence or qualifications of health care professionals; evaluating agency performance; conducting training programs with students or new employees; licensing, survey certification, accreditation and credentialing activities; internal auditing and certain fundraising and marketing activities. For example, our agency periodically holds performance improvement/clinical record review meetings where the consulting professional of our record review committee will audit clinical records for meeting professional standards and utilization review.

The following uses and disclosures do not require your consent, and include, but are not limited to, a release of information contained in financial records and/or medical records including information concerning communicable diseases such as Human Immune Deficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), drug/alcohol abuse, psychiatric diagnosis and treatment records and/or laboratory test results, medical history, treatment progress and/or any other related information to:

1. Your insurance company, self-funded or third-party health plan, Medicaid or any other person or entity that may be responsible for paying or processing for payment any portion of your bill for services; 2. Any person or entity affiliated with or representing us for purposes of administration, billing and quality and risk management; 3. Any hospital or other health care facility to which you may be admitted; 4. Any physician providing you care; 5. Licensing and accrediting bodies; 6. Contacting you to provide appointment reminders or information about other health activities we provide; and 7. Other health care providers to initiate treatment.

We are permitted to use or disclose information about you without consent or authorization in the following circumstances:

1. In emergency treatment situations, if we attempt to obtain consent as soon as practicable after treatment; 2. Where substantial barriers to communicating with you exist and we determine that the consent is clearly inferred from the circumstances; 3. Where we are required by law to provide treatment and we are unable to obtain consent; 4. Where the use of disclosure of medical information about you is required by Federal, State of local law; 5. To provide information to State or Federal public health authorities, as required by law to: prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify persons of recalls of products they may be using; notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence (if you agree or when required or authorized by law); 6. Health care oversight activities such as audits, investigations, inspections and licensure by a government health oversight agency as authorized by law to monitor the health care system, government programs and compliance with civil rights law; 7. Certain judicial administrative proceedings if you are involved in a lawsuit or a dispute. We may disclose medical information about you in response to a court or administrative orders, a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested; 8. Certain law enforcement purposes such as helping to identify or locate a suspect, fugitive, material witness or missing person, or comply with a court order or subpoena and other law enforcement purposes; 9. To coroners, medical examiners and funeral directors, in certain circumstances, for example, to identify a deceased person, determine the cause of death or to assist in carrying out their duties; 10.For cadaver, organ, eye or tissue donation purposes communicate to organizations involved in procuring, banking or transplanting organs and tissues (if you are an organ donor); 11.For certain research purposes under very select circumstances. We may use your health information for research. Before we disclose any of you health information for such research purposes, the project will be subject to an extensive approval process. We will usually request your written authorization before granting access to your individually identifiable health information; 12.To avert a serious threat to health and safety: To prevent or lessen a serious and imminent treat to the health or safety of a particular person or the general public, such as when a person admits to participation in a violent crime or serious harm to a victim or is an escaped convict. Any disclosure, however, would only be to someone able to help prevent the threat; 13.For specialized government functions, including military and veterans’ activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institution and custodial situations; and 14.For Workers’ Compensation purposes: Workers’ compensation or similar programs provide benefits for work-related injuries or illness.

We are permitted to use or disclose information about you without consent or authorization provided you are informed in advance and given the opportunity to agree to or prohibit or restrict the disclosure in the following circumstances:

1. Use of a directory (includes name, location, condition described in general terms) of individuals served by Reach Pediatric Therapy Center ; and 2. To a family member, relative, friend, or other identified person, the information relevant to such person’s involvement in your care or payment for care; to notify family member, relative, friend, or other identified person of the individual’s location, general condition or death. Other uses and disclosures will be made only with your written authorization. That authorization may be revoked, in writing, at any time, except in limited situations.

YOUR RIGHTS – You have the right, subject to certain conditions, to:  Request restrictions on uses and disclosures of your protected health information for treatment, payment or health care operations. However, we are not required to agree to any requested restriction. Restrictions to which we agree will be documented. Agreements for further restrictions may, however, be terminated under applicable circumstances (e.g., emergency treatment).  Confidential communication of protected health information. We will arrange for you to receive protected health information by reasonable alternative means or at alternative locations. Your request must be in writing. We do not require an explanation for the request as a condition of providing communications on a confidential basis and will attempt to honor reasonable requests for confidential communications.  Inspect and obtain copies of protected health information which is maintained in a designated record set, except for psychotherapy notes, information compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative action or proceeding, or protected health information that is subject to the Clinical laboratory Improvements Amendments of 1988 [42 USC § 263a and 45 CFR 4932 § (a)(2)]. If you request a copy of your health information, we will charge a reasonable fee for copying of $0.25 per page copied. If we deny access to protected health information, you will receive a timely, written denial in plain language that explains the basis for the denial, your review rights and an explanation of how to exercise those rights. If we do not maintain the medical record, we will tell you where to request the protected health information.  Request to amend protected health information for as long as the protected health information is maintained in the designated record set. A request to amend your record must be in writing and must include a reason to support the requested amendment. We will act on your request within 30 days of receipt of the request. We may extend the time for such action by up to 30 days, if we provide you with a written explanation of the reasons for the delay and the date by which we will complete action on the request. We may deny the request for amendment if the information contained in the record was not created by us, unless the originator of the information is no longer available to act on the requested amendment; is not part of the designated medical record set; would not be available for inspections under applicable laws and regulations; and the record is accurate and complete. If we deny your request for amendment, you will receive a timely, written denial in plain language that explains the basis for the denial, your rights to submit a statement disagreeing with the denial and an explanation of how to submit that statement.  Receive an accounting of disclosures of protected health information made by our Agency for up to six (6) years prior to the date on which the accounting is requested for any reason other than for treatment, payment or health operations and other applicable exceptions. The written accounting includes the date of each disclosure, the name/address (if known) of the entity or person who received the protected health information, a brief description of the information disclosed and a brief statement of the purpose of the disclosure or a copy of your written authorization or a written request for disclosure. We will provide the accounting within 60 days of receipt of a written request. However, we may extend the time period for providing the accounting by 30 days if we provide you with a written statement of the reasons for the delay and the date by which you will receive the information. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.  To obtain a paper copy of this notice, even if you had agreed to receive this notice electronically, from us upon request.

COMPLAINTS – If you believe that your privacy rights have been violated, you may complain to the Agency (Reach Pediatric Therapy Center ), or to the Secretary of the U.S. Department of Health and Human services. There will be no retaliation against you for filing a complaint. The complaint should be filed in writing, and should state the specific incident(s) in terms of subject, date and other relevant matter. A complaint to the secretary must be filed in writing within 180 days of when the act or omission complained of occurred, and must describe the acts or omissions believed to be in violation of applicable requirements. [45 CFR § 160.306] For further information regarding filling a complaint, contact:

Sue Muenks, Privacy Officer Reach Pediatric Therapy Center Phone: (713) 383-9700

EFFECTIVE DATE – This notice is effective April 14, 2003. We are required to abide by the terms of the notice currently in effect, but we reserve the right to change these terms as necessary for all protected health information that we maintain. If we change the terms of this notice (while you are receiving service), we will promptly revise and distribute a revised notice to you as soon as practicable by mail, e-mail (if you have agreed to electronic notice) or hand delivery.

If you require further information about matters covered by this notice, please contact:

Reach Pediatric Therapy Center 9220 Kirby Drive Suite 1000 Houston, TX 77054 Phone: (713) 383-9700

III. ABUSE, NEGLECT AND EXPLOITATION REPORTING

Reach Pediatric Therapy Center employees, volunteers and contractors have the legal obligation to report suspected abuse, neglect or exploitation to the Department of Family and Protective Services (DFPS) at 1-800-252-5400. Any finding supporting the possibility of abuse, neglect or exploitation must be reported to the appropriate local authorities and the patient’s physician. The agency will report all suspected cases of abuse, neglect or exploitation in compliance with appropriate state statutes to appropriate protective organizations.

If the therapist suspects the caregiver of patient is a victim of domestic violence, they will report this to: 1-800-799-SAFE (7233) – The National Domestic Violence Hotline (located in Texas).

Any individual who is legally mandated to report suspected abuse and / or neglect and who intentionally fails to report such suspected abuse/neglect is guilty of a misdemeanor and liable for damages caused by failure. An individual who willingly makes a false abuse and / or neglect report is liable for civil action for any damages suffered by individuals who were reported as suspects in such abuse and / or neglect. IV. EMPLOYEE BACKGROUND CHECKS

Reach Pediatric Therapy Center implements a comprehensive drug and alcohol screening program. Employees are tested for illegal substances before their employment begins with Reach Therapy Center. In addition, we reserve the right to conduct further testing with suspected use or as a random screening. The manufacturing, distribution, dispensing, possession, sale, purchase, or use of a controlled substance on company property is strictly prohibited. Being under the influence of alcohol or illegal drugs, unauthorized use of prescription drugs or the abuse of over- the counter drugs on company property is prohibited. This applies to all employees of Reach Pediatric Therapy Center regardless of position. In addition, criminal background checks are run at regular intervals to identify any employee who may have been convicted of criminal activity.

V. INFECTION CONTROL

Reach Pediatric Therapy Center will utilize universal precautions as a means to ensure infection control. Universal precautions are intended to supplement rather than replace recommendations for routine infection control practices, such as hand washing, using gloves to prevent contamination, and sanitizing equipment. Because specifying the types of barriers needed for every possible clinical situation is impractical, some judgment must be exercised. Standard precautions used by our employees include hand washing and antisepsis, use of personal protective equipment when handling blood, body substances, excretions and secretions, appropriate cleaning of patient care equipment, toys and soiled linens, regular environmental cleaning, and spills management.

In addition, any illnesses are documented regularly in our Infection Control log as mandated by state standards to identify trends and control communicable illness.

VI. CONSENTS

As part of the admission process, we ask for your consent to provide services, release information relative to your care, and allow us to collect payments directly from your insurer. You or your legal representative must sign this consent before we can admit you.

Consent for Treatment

PATIENT RIGHTS AND RESPONSIBILITIES: I acknowledge that I have been given a copy of my rights and responsibilities. I acknowledge that I have chosen this agency to provide health care. No employee of this agency has solicited or coerced my decision in selecting a health care agency. The Health Facility Compliance Group (MC 1979) Texas Department of State Health Services Complaint hotline is (888) 973-0022, its purpose and hours of operation have been explained to me. I understand that I may also submit my complaint in writing to Health Facility Compliance Group (MC 1979), Texas Department of State Health Services PO Box 149347, Austin, TX 78714-9347. I have received notification that the agency may not retaliate against a person for filing a complaint, presenting a grievance or providing in good faith information relating to health care services provided by the agency. I have received a copy of the agency policy on Abuse, Neglect and Exploitation and the agency policy on drug testing of employees. I have been educated on how to access care from the agency or another health care provider after regular business hours. CONSENT FOR TREATMENT: I hereby give my permission for authorized personnel of your agency to perform all necessary procedures and treatments as prescribed by my physician for the delivery of outpatient services. I understand that the agency will supervise services provided, I may refuse treatment or terminate services at any time, and the agency may terminate their services to me as explained in my orientation. I agree and consent to the care plan and payment as outlined in this admission booklet. In the event an agency employee is exposed to my blood or other body fluids, I agree to have my blood tested for HIV/Hepatitis and the results released to the agency/exposed person, but not to anyone else unless required/authorized by law. Service Frequency Cost Ins. Pays You Pay Physical Therapy Occupational Therapy Speech Therapy I understand that this is the initial plan and I will be notified by the agency each time there are changes made in my plan of treatment. RELEASE OF INFORMATION: I acknowledge receipt of the Notice of Privacy Practices and was given an opportunity to ask questions and voice concerns. I understand that the agency may use or disclose protected health information about me to carry out treatment, payment or healthcare operations. I hereby authorize your agency to release to or receive from hospitals, physicians or other agencies/auditors involved in my care all medical records and information pertinent to my care. I hereby give permission for the review of my medical record by the agencies accrediting and /or other regulatory bodies. AUTHORIZATION FOR PAYMENT: I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize release of all records required to act on this request. I request that payment of authorized benefits from Medicare, Medicaid or other responsible payer be made on my behalf to Reach Pediatric Therapy Center. If I have Medicare Part A or Medicaid benefits, I understand that Medicare Part A/Medicaid payments will be accepted as payment in full and I have no financial liability unless I have been notified in writing that service(s) will not be covered by Medicare PartA/Medicaid and wish to receive the care or service. I understand that while I am on my own, I understand that Medicare will not reimburse me or my supplier and I will be responsible for the total cost. If I have other insurance, I may be responsible for the co-payment and any charges that my insurance will not cover I am free to request the maximum rates for services schedule provided by the agency for the exact dollar amounts that I may be required to pay. I understand that I am responsible for all amounts not paid by my insurance. If I am a Private Pay patient, I agree to pay for all services rendered by the agency. CONSENT TO PHOTOGRAPH: I hereby authorize the agency to photograph myself and my child and treatment being done as well as the release of those photographs for use in advertisement or public education regarding therapy services or to insurance providers to document my medical condition.

I understand a copy of this consent form shall be as valid as the original and shall remain in effect until I am discharged from the agency. I also understand that I may revoke this consent in writing at any time.

______Patient’s Name Patient ID# Responsible Person or Legal Guardian Signature ______Witness/Agency Representative Signature Date Printed Name & Relationship of Person above

Unable to sign due to: ______

Responsible Person’s Address and contact information:______

______

ASSIGNMENT OF BENEFITS

Patient Name:______Patient #:______Date:______

I hereby agree to accept the services of Reach Pediatric Therapy Center and to cooperate with the staff in the planning and execution of my care. I agree to immediately inform Reach Pediatric Therapy Center in writing of any change in my insurance coverage. My failure to do so may result in my responsibility of payment of any un-reimbursed service delivered by Reach Pediatric Therapy Center. In consideration of services rendered, this irrevocable Assignment of Benefits and Authorization to Pay is made as of______20______to Reach Pediatric Therapy Center. This agreement is made by me or on behalf of my dependents. 1. I hereby irrevocably assign to Reach Pediatric Therapy Center all claims against all third parties and any and all insurance benefits payable to me or on my behalf with respect to services rendered to me or to my dependent by Reach Pediatric Therapy Center from any insurance policy, health care plan or other responsible third party. 2. I authorize and direct any and all insurance carriers or employer self-insurance plans of which I or my dependent is a beneficiary to pay directly to Reach Pediatric Therapy Center all such benefits payable with respect to such services. 3. I understand that Reach Pediatric Therapy Center allows 45 days from the date a claim was filed by their office for insurance company to pay. If the insurance carrier has not paid within this time, I am responsible for the entire balance without further notice. I understand that Reach Pediatric Therapy Center will not become involved in disputes between me and my insurance company regarding deductibles, non-covered services, coinsurance, co-payments, coordination of benefits, pre-existing conditions or reasonable and customary charges other than to supply factual information when necessary. I am responsible for the timely payment of my account. 4. I shall have no obligation to pay Reach Pediatric Therapy Center any amounts that are restricted by state or federal laws or contractual agreement with my insurance carriers. 5. I acknowledge that if I have assigned to Reach Pediatric Therapy Center my right to receive payment from the Medicare/Medicaid Program, then I shall have no obligation to pay Reach Pediatric Therapy Center any amounts except 1.) applicable co-insurance and deductibles and 2.) any items or service not billable to or covered by Medicare/Medicaid for which I am ineligible under Medicare/Medicaid criteria. 6. I agree for myself and my dependent to cooperate with Reach Pediatric Therapy Center in any efforts undertaken to collect such benefits including without limitation, authorizing release of information from health care providers or others, and executing additional documentation to evidence or support this assignment. 7. I understand that if I change insurance (including enrolling in a Medicare Advantage Plan, Medicaid HMO or hospice) during the course of care, or am notified of a change in coverage, I am obligated to inform Reach Pediatric Therapy Center prior to the last date of coverage. If I fail to inform Reach Pediatric Therapy Center in a timely manner, I understand that I will be obligated to pay for services. ______Responsible Person or Legal Guardian Signature Patient Signature

______Printed Name & Relationship of Person above Witness/Agency Representative Signature

Patient unable to sign due to:______

CANCELLATION GUIDELINES

Patient Name ______Date______MR#______

Reach Pediatric Therapy Center is proud to have the opportunity to work with your child. Our staff works very hard to coordinate schedules and provide the services needed to maximize your child’s potential. The following guidelines are important to help us provide the best therapy for your child and optimize our therapists’ busy schedules.

 Expected Attendance -Expected attendance rate is 80% per month. Any patient with recurring poor attendance (<80%) will receive a warning to improve attendance. Please be aware that your child may occasionally be seen by an alternate therapist in the case of cancellations, staff vacations, or schedule changes.  Poor Attendance - Poor attendance after warning may result in loss of current appointment time or discharge of therapy services.  Illness - Please call your therapist to cancel your appointment prior to your appointment time if your child has a fever over 100.4, vomiting or diarrhea in the past 24 hours or if you kept your child home from school or daycare due to illness.  No show/no call- If you are not at the clinic at your scheduled appointment time and do not call to cancel, our staff will give you a reminder of our cancellation guideline after the 1st incident. Your child may be discharged after 2nd no call/no show incidents. (Exceptions may be made at the director’s discretion on a case by case basis.)  Late arrivals - We have a scheduled end time for each treatment session. If you are late for a scheduled treatment session, your child may not be seen for their full treatment time. Excessive late arrivals will be counseled and are at risk of being placed on the waitlist.  Current Contact information - Please update your therapist with any changes to your contact information. Any changes to your schedule will be communicated with you through the phone number provided upon admission. If your therapist can not contact you after a missed visit as outlined above, your child will be discharged from therapy. It is important to maintain a consistent treatment schedule in order for your child to achieve his or her therapy goals. Unscheduled cancellations are only acceptable when due to patient illness or unforeseen emergencies. To avoid conflicts in scheduling and possible missed visits, please arrange routine physician appointments and other obligations around your child’s established therapy schedule. If you have any questions concerning the cancellation guideline, please do not hesitate to call us.

Mimi Branham, MA, CCC-SLP, Clinic Director- Central and South Locations 713- 383-9700 ext 2450 Beth Hancock, DOTR, Clinic Director- Northwest Location 713-383-9700 ext 2708

______Therapist Signature Parent/Guardian Signature PARENT ACKNOWLEDGEMENTS

Please initial at the end of each statement:

I acknowledge that attendance is not only monitored by Reach, but may also be monitored by my insurance/Medicaid company and used by them to determine the need for continued services. I understand that failure to attend therapy at ordered frequency may result in discharge. ______

I understand and agree to follow the home program as set forth by my therapist to optimize my child’s full potential in meeting his/her therapy goals. _____

I will provide hearing and vision assessment results to Reach if required by my insurance/Medicaid for authorization within the required timeframe. _____

I understand that I may be required to have a Texas Health Steps screening and/or developmental assessment completed by my MD in order to receive services. I agree to contact my child’s MD if necessary to complete a TH Steps screening and/or developmental assessment(s) if required. _____

I agree that I will assist Reach in obtaining any additional documentation from other medical professionals to assure my child is able to receive therapy services. _____

For Children 3 years and under please initial one: ____I have been referred to and evaluated by ECI for services. ____I have been referred to ECI services and I have refused all ECI services. ____I have been referred to ECI services and receive services other than those being evaluated by Reach. ____I have been referred to ECI and I am waiting for an assessment by ECI. ____I have not been referred to ECI and would like to be referred to them.

______Parent Signature Patient Name

______Therapist Signature Patient DOB Date PENDING INITIAL AUTHORIZATION

Patient: ______Date: ______

Insurance/Medicaid: ______MR#: ______

The patient/caregiver requests the following action pending authorization of therapy services from insurance/Medicaid.

 I wish to have my initial services held pending approval / authorization from my insurance company / Medicaid.

 I wish to receive services as ordered. I understand that I will be required to pay for these services upon delivery and I understand that monies will be refunded to me upon authorization from insurance company / Medicaid.

**Copayments/Cash Payments must be arranged through our Billing Department.**

 I am refusing services from the agency.  Physician Notified  Referral Source Notified

Therapist has verified current insurance/Medicaid company is:

Patient signature upon admission: ______

Employee Signature upon admission: ______

Patient approval per telephone/(date and employee initials): ______

CHANGE OF PROVIDER

ATTENTION:

REGARDING:

Medicaid #:

To Whom It May Concern:

This is to notify you of a change in therapy services for my child. My child was previously receiving ______services from ______but was discharged from their services effective ______. We have changed providers because ______. The new facility providing therapy services is Reach Pediatric Therapy Center. To prevent a delay in my child’s ability to receive therapy, please release any previous insurance authorization so Reach Pediatric Therapy Center can begin providing therapy services for my child. We thank you for your prompt attention to this request.

______Parent/Legal Guardian

______Date CONSENT TO SHARE INFORMATION AND AUTHORIZATION OF ACCOMPANYMENT

Patient Name: ______MR#: ______

The following caregivers are approved to accompany my child while he/she is receiving therapy services at Reach Pediatric Therapy Center. I grant these persons the right to transport my child to and from therapy. Reach Pediatric Therapy Center may contact these persons, in the event of an emergency situation, if I as the Primary Caregiver am unable to be contacted. Additionally, by signing this form, I am granting Reach Pediatric Therapy Center permission to share information regarding my child’s approved plan of care and any therapeutic methods associated with plan of care with the following people:

1) PRIMARY CAREGIVER Name: ______

Relation to child: ______

Phone #1: ______Phone #2: ______

2) ALTERNATE CAREGIVER NAME: ______

Relation to child: ______

Phone #1: ______Phone #2: ______

3) ALTERNATE CAREGIVER NAME: ______

Relation to child: ______

Phone #1: ______Phone #2: ______

I give permission for the above person(s) to transport my child to and from therapy, to be contacted by Reach Pediatric Therapy Center personnel if we cannot contact the Primary Caregiver, and/or in an emergency situation. I understand that Reach Pediatric Therapy Center personnel will require picture identification verification when an Alternate Caregiver brings and/or takes home my child.

If Reach Pediatric Therapy Center personnel deem the present caregiver unfit to transport the child for the sake of the child’s safety and health, I understand that Reach Pediatric Therapy Center personnel will notify their Clinic Administrator(s) and A) Call an alternate caregiver(s) listed above to request another person to retrieve the child, B) Call a cab to transport the child [with the primary caregiver responsible to pay the cab fare], and/or C) Will call 911, the local police, and/or CPS to report the situation.

______Parent Signature Date

SICK/COMMUNICATABLE DISEASE POLICY

It is the policy of Reach Pediatric Therapy Center that in the event your child becomes ill, Reach will utilize the following guidelines regarding illnesses and the health and safety of our patients. Cancel appointment if ANY of the below conditions are present:  Oral temperature of 100 degrees or above  Vomiting, nausea, or severe abdominal pain  Marked drowsiness or malaise  Sore throat, acute cold, or persistent cough  Red, inflamed, or discharging eyes  Acute skin rashes or eruptions  Swollen glands around jaws, ears, and/or neck  Suspected scabies or impetigo  Any skin lesion in the weeping stage  Earache  Pediculosis (head lice)  Diarrhea  Other symptoms suggestive of acute illness

Return to therapy guidelines:  Fever Free for 24 hours  Symptom free of vomiting, nausea or severe abdominal pain  Symptom free of marked drowsiness or malaise  Symptom free of sore throat, acute cold, or persistent cough  Treated pediculosis (head lice)  Symptom free of diarrhea  All other health conditions listed above have been treated and resolved I agree to cancel my child’s appointment in the event of illness (es) and attempt to reschedule my child’s appointment after the illness (es) have been treated and/or resolved. Initial______

Student Observers I understand that Reach offers students in the field of speech, physical and occupational therapy the opportunity to observe therapy sessions. I authorize Reach to allow a student to observe my child during therapy. I understand that the student will be required to sign a confidentiality statement and will not be involved in the therapeutic process. Initial ______

I have read and understand the above policies stated above.

______Caregiver/Parent Signature Date

Patient: ______

YOUR REHAB THERAPIST(S) IS/ARE:

PT ______ext. ______

OT ______ext. ______

ST ______ext. ______

Please call your Rehab Therapist if :

1* You go to the doctor’s office or hospital 2* You call the doctor’s office and receive new instructions/orders 3* You have any questions/requests regarding you or your child’s care

YOUR REHAB SUPERVISOR(S) IS/ARE:

PT Supervisor – Jessica Plaza, x2504 OT Supervisor – Sue Muenks , x2220 ST Supervisor – Monique Sterling, x2505 Therapy Supervisor, Pearland – Sara McConathy x 2484

Please call your REHAB SUPERVISOR if:

You have any concerns that cannot be handled through your Rehab Therapist.

Call Reach after hours by calling 713-383-9700 for the answering service after hours, Monday - Friday between 5 P.M. and 8:30 A.M., and weekends. Please let the service know if your call is urgent. If you have not had your afterhours call returned within 30 minutes, please call back.

If you have concerns that cannot be answered by any of the above, you may call:

MIMI BRANHAM MA, CCC-SLP-CENTRAL and PEARLAND CLINIC DIRECTOR, 713-383-9700 ext 2450 BETH HANCOCK DOTR –NORTHWEST CLINIC DIRECTOR, 713-383-9700 ext 2708 TARA ALDRED, OTR –DIRECTOR OF OPERATIONS, 713-383-9700 EXT 2469

REHAB PATIENT / FAMILY SURVEY – Clinic

Dear Patient / Parent / Caregiver, This survey has been developed to gather information that will help us meet your needs in providing home care to you and your family. Once completed, please return it to our office in the attached self-addressed, postage paid envelope. Your opinion is important to us! 1 -Strongly 2-Disagree 3-Agree 4 -Strongly Disagree Agree

  I was included in the planning of 1 2 3 4 my child’s needs. Services and insurance 1 2 3 4 authorization process (if applicable) were explained to me. The staff has been courteous 1 2 3 4 and prompt on the telephone & in person. Reach was 1 2 3 4 prompt in initiating services I am satisfied with the care my 1 2 3 4 child receives from Reach. Question and concerns were 1 2 3 4 handled promptly and efficiently. Questions regarding my bill 1 2 3 4 were resolved to my satisfaction.

Comments:______Name: (Optional)______Phone: (Optional)______

Date: ______

Telephone survey by:______