Kidz Therapy Services, PLLC

______Child’s Name

POLICIES AND PROCEDURES

PARENT ACKNOWLEDGEMENT FORM

I have received a current copy of Kidz Therapy Services Policies and Procedures.

By signing below, I acknowledge that I have read and will comply with all policies and procedures, including the Sick Child and Waiting Room Policies.

Since policies and procedures are subject to change, I acknowledge that revisions may occur. All such changes will be communicated to me through official notices. I understand that all revisions supersede, modify or eliminate existing policies.

______Parent Signature Date

______Email Address

______FOR OFFICE USE ONLY:  Acknowledgement Form  Medicaid Parental Consent Form  Emergency Information Form  Rx:  ST  OT  PT 2 Email Consent Form

Welcome to Kidz Therapy Services! We look forward to working with you and your child. There are several policies and procedures that we would like to review at this time to ensure a positive experience for all.

Attendance/General Policies -Consistent and timely attendance is necessary for your child’s progress.

-You or a designated caregiver (must complete Alternate Signature form) must sign the therapist’s log notes after each session. Do not sign blank therapy log notes.

-If you are unable to keep your child’s scheduled appointment, you must contact your child’s provider prior to your appointment. We encourage make-up sessions and every attempt will be made to schedule a make-up session pending the provider’s availability.

-As per Suffolk County regulations, make-ups must occur within two weeks for related services (speech, occupational therapy, physical therapy and counseling), following the missed session. The same service cannot be provided two times in one day even if your child has two different therapists (no make-ups on the same day as regular sessions). There are no make-ups allowed for services that are provided five days per week.

-Rescheduled sessions can be provided for legal holidays within the same week as the holiday, only if the therapist’s schedule permits.

Therapy Specifics -Discussion of your child’s progress and parental participation is considered an essential part of the therapy process. Formal reviews of progress reports or annual reviews will take place in accordance with the schedule designated on the IEP.

-A current doctor’s prescription must be on file before Occupational Therapy or Physical Therapy can begin. If we do not have the appropriate form, the therapist is not allowed to see your child. Any changes in medical status (i.e. broken bones, stitches, hospital visits, require a medical clearance from your doctor).

-You must complete, sign and return all included forms at the first session. If someone other than you brings your child to their first session, these forms must be returned to us by the second session.

Delivery of Services – All decisions regarding the delivery of services are indicated in your child’s Individualized Educational Program (IEP). Please read the IEP very carefully. If the IEP indicates “Follow the Kidz Therapy Services calendar”, then services may be provided on any day that Kidz Therapy is open. If this is not specifically stated on the IEP, then we must follow your local school district’s calendar. Preschool services (speech therapy, occupational therapy, physical therapy, social skills group, pragmatic group, etc.) cannot be provided on any day listed as holiday or school closed on your school district calendar. We can, however, attempt to provide individual services on a different day during that week, if schedules permit. Group services cannot be rescheduled. If your local school district’s calendar indicates “Superintendent’s or Teacher’s Conference Day”, services can be provided since the school district is still open. If your school district closes for a Snow Day, services may be provided in the clinic if the office is open. Please check the Kidz Therapy Services website for information regarding closures, delayed openings or early closings. Record Access All information in your child's file is confidential. You as the parent or legal guardian have the right to access the file at any time. If you need any records from your child's file, you may call the Office Manager at 631-382-7311 to request a copy of your child’s records. At that time a written request must be submitted.

Moving – From one District to Another District You must notify Kidz Therapy one month prior to moving from one district to another district, to ensure no lapse in services. If Kidz Therapy is not notified, parents will be financially responsible for any services rendered after the move. You must withdraw from your current school district and register at your new school district (bring current IEP) as soon as possible.

If you have any questions regarding attendance please feel free to contact us.

Sincerely,

______Judy Mahoney, MA, CCC-SLP Theodora Thomas, MA, CCC-SLP Clinic Director-Nassau Clinic Director-Suffolk

8/2016 4 School District:______Medicaid Consent

Dear Parent/ Guardian of ______: (Print child’s name) This is to ask your permission (consent) to bill your or your child’s Medicaid Insurance Program for special education and related services that are on your child's Individualized Education Program (IEP). This consent allows the School District/Nassau County to bill for covered health-related services and to release information to the school district’s Medicaid Billing Agent for that purpose. I, ______, as the parent/guardian of ______, (Print Parent and Child’s names) have received a written notification from the School District that explains my federal rights regarding the use of public benefits or insurance to pay for certain special education and related services.

I understand and agree that the School District/ Suffolk County may access Medicaid to pay for special education and related services provided to my child.

I understand that: providing consent will not impact my child’s/my Medicaid coverage; upon request, I may review copies of records disclosed pursuant to this authorization; services listed in my child’s IEP must be provided at no cost to me whether or not I give consent to bill Medicaid; I have the right to withdraw consent at any time; and the School District must give me annual written notification of my rights regarding this consent.

I also give my consent for the School District/ Nassau County/ Providers to release the following records/information about my child to the State’s Medicaid Agency for the purpose of billing for special education and related services that are in my child’s IEP. The following records will be shared. Records to be shared (such as records or information about services your child receives) Prescription Service Provider Attendance Referral “Under the Direction of” Certification Treatment Logs “Under the Supervision of” Certification Individualized Education Program - IEP “Under the Direction of” Logs Attendance Records “Under the Supervision of” Logs Bus Logs Calendar Other unnamed documents needed to support a claim to Medicaid I give my consent voluntarily and understand that I may withdraw my consent at any time. I also understand that my child’s right to receive special education and related services is in no way dependent on my granting consent and that, regardless of my decision to provide this consent, all the required services in my child’s IEP will be provided to my child at no cost to me.

Parent/Guardian Signature: ______

Print Name: ______Date: ______

CHILD EMERGENCY INFORMATION

Child’s Name: ______Child’s Home Address: ______Child’s Home Phone: ______Mother’s Name: ______Father’s Name: ______Mother’s Cell: ______Father’s Cell: ______Mother’s Work #: ______Father’s Work #:______Mother’s Email: ______Father’s email: ______Guardian Name/Relationship: ______Guardian Cell: ______Guardian Work: ______

8/2016 6 We must have 3 additional emergency contacts: NAME RELATIONSHIP TELEPHONE #

1.______

2.______

3.______

Medical Alerts Please list any medical conditions (asthma, diabetes, seizures, etc) your child has:

______

Allergies -Please list any allergies (foods, latex, etc.) your child has – please be specific:

______

It is your responsibility to notify each therapist of your child’s allergies and/or medical conditions/alerts. If there is a change in medical status of your child, please notify the office immediately. If any allergies are indicated, attach documentation including identification of the allergy, prevention of exposure and plan to treat an allergic reaction.

Pediatrician Name/Phone: ______Parental Consent to Use E-mail to Exchange Personally Identifiable Information

Parent’s Name: ______

E-mail Address: ______

Child’s Name: ______DOB: ______At your request, you have chosen to communicate personally identifiable information concerning your child's treatment by e-mail without the use of encryption. Sending personally identifiable information by email has a number of risks that you should be aware of prior to giving your permission. These risks include, but are not limited to, the following:  E-mail can be forwarded and stored in electronic and paper format easily without prior knowledge of the parent.  E-mail senders can misaddress an e-mail and personally identifiable information can be sent to incorrect recipients by mistake.  E-mail-sent over the internet without encryption is not secure and can be intercepted by unknown third parties.  E-mail content can be changed without the knowledge of the sender or receiver  Backup copies of e-mail may still exist even after the sender and receiver have deleted the messages.  Employers and on-line service providers have a right to check e-mail sent through their systems.  E-mail can contain harmful viruses and other programs.

Parental Acknowledgement and Agreement I acknowledge that I have read and understand the items above which describe the inherent risks of using e-mail to communicate personally identifiable information. Nevertheless, I, ______Authorize ______whose email address is ______to communicate with me at my email address, ______, concerning my child's participation in the EIP (Early Intervention Program), CPSE or CSE. including but not limited to communication, regarding service delivery, his/her progress of the IFSP or IEP and any other related matters. I understand that use of e-mail without encryption presents the risks noted above and may result in an unintended disclosure of such information. (Optional) In addition, I give permission for members of my child's treatment team to communicate personally identifiable information concerning my child with each other using unencrypted e-mail. Team members who I give permission to use unencrypted e-mail to communicate with each other about my child include:

(1)______with the e-mail address ______(2)______with the e-mail address ______(3)______with the e-mail address ______(4)______with the e-mail address ______(5)______with the e-mail address ______

Parent's Signature:______Date______

8/2016 8

SICK CHILD POLICY

In order to avoid spreading germs and re-infecting children and staff, the following guidelines are in effect immediately -

 Child must be fever-free for 24 hours.

 Vomiting/diarrhea - child must be symptom-free for 24 hours.

 Infectious diseases including, but NOT limited to, strep, pink eye, lice, and ringworm - child must have a doctor’s note before he/she can return for therapy.

 Broken bones/severe sprains/stitches/any medical procedure - child must have a doctor’s note before he/she can resume therapy.

 If your child will not be in for a scheduled appointment, call your child’s provider 24 hours ahead of time, or as soon as possible. Make ups will be provided according to the provider’s availability.

Remember, you are the Parent and if your child is sick you need to cancel the session even if they want to “play”. We appreciate your cooperation in this matter.

KIDZ THERAPY/GEK THERAPEUTIC RESOURCES STAFF