Welcome to Therapy West, Inc. We appreciate the opportunity to work with you and your child. The following policies have been designed to help guide you through the procedures at Therapy West, Inc.
THERAPY ATTENDANCE POLICY
Attending 80% of therapy appointment is mandatory. Attendance rates below 80% or not calling to cancel a scheduled appointment will not be tolerated and will result in having your child be placed on the waiting list. Clients with 2 no shows will be removed from the schedule immediately.
If your child is ill, please call to cancel your appointment. If your child has a prolonged illness (2 consecutive cancellations due to illness) or contagious illness, you must bring a medical clearance from your doctor in order to resume therapy.
To cancel an appointment, please notify your therapist or leave a message at (310) 337-7115 extension #0 (the operator). When leaving a message, please include the time of appointment being canceled, the therapist(s) name and the available days and times the session can be made up.
Make up sessions are not guaranteed and are subject to time and therapist availability. Therefore make up sessions are usually not at the same time or day and may not be with your regular therapist.
In fairness to all children including those on our waiting list, please note the cancellation policy (per funding agency).
Regional Center, School District & Easter Seals clients: i. Clients must maintain 80% attendance. ii. Clients with 2 no shows will be removed from the schedule immediately.
Insurance & Private Pay clients : i. Clients must maintain 80% attendance. ii. Clients with 2 no shows will be removed from the schedule immediately. iii. Clients are allowed 3 cancellations per calendar year that are given with less than 24 hour notice. Starting on the 4th cancellation, the client will be charged a $75 fee per session if cancelled with less than 24 hour notice.
If you have questions or require more time to talk with your therapist, please make an appointment to talk later by telephone. Consultations (in person or on the phone) that exceed 10 minutes will be charged in 15 minutes increments at the rate of a private therapy session.
It is mandatory that your child be picked up on time after their session. A $20.00 per 15 minutes or fraction thereof will be charged to the parent and must be paid at the time of pick up.
If you are leaving the premises during your child’s therapy time, please make sure that your therapist has a means of contacting you.
Therapy sessions are often video taped by your treating therapist (especially if your child is under 1 year of age) for record keeping documenting progress and in order to assist your therapist with future treatment planning. Videos are also used for other educational purposes. Photographs are taken regularly for our TW newsletters or to display on our walls at Therapy West. A photo/videotape release form is included in your new client packet for this purpose. It is optional to sign this release and you are free to stipulate the terms for videotaping and photographing your child. You may be asked to provide Therapy West a copy of any home videos that you have of your child between 8-12 months of age (which will be kept confidential). This is helpful in better understanding the early development of your child.
CREDIT CARD ON FILE:
In order to receive services at Therapy West, the Responsible Party must maintain an active credit card on file and must be provided before the evaluation or first therapy session. By signing below, you are agreeing to being charged for co-pays, cost shares, cancellation penalties and any outstanding balances. You are responsible to ensure that the credit card is valid and up to date.
CREDIT CARD NOT ON FILE:
If you do not want your credit card on file, you are indicating that all payments will be made within 2 weeks of statement received. If a payment is not made within 2 weeks of statement received, you will be removed off the schedule until a payment is received.
For private paying clients, payment is expected at each session. We accept Visa, MasterCard, AMEX and Discover. If for some reason you are not able to make a payment at the time of your child’s therapy session, a late charge equivalent to 10% will be added.
Therapy West is now able to bill some insurance companies directly. Please fill out the Billing Information portion on the New Client packet (goldenrod form). If we are not contracted with your insurance company, parent is responsible for payment at start of session. We will provide an invoice that is coded and provides the standard information required by most medical insurance companies for reimbursement (i.e. superbill). If there is any additional information that you or your insurance company may need, please contact our billing department at x553.
A doctor’s prescription is required and you may be asked to update it periodically. A prescription must include: 1) medical diagnosis with diagnosis code, 2) therapy type (e.g., OT, PT, or SL), 3) service requested (e.g., evaluation, treatment), 4) frequency and duration of treatment (e.g., 2x/week for 12 months). A copy of the front and back of your insurance card is also required.
SCHOOL FUNDED THERAPY SESSIONS
Although there are some differences in policy depending on the school district, generally children are not funded when they are not in school. We are not allowed to make up therapy sessions regularly scheduled on a school holiday, etc. Most school districts do not allow us to provide a make-up if you cancel a session.
It is the parent’s responsibility to notify the therapist(s) of school holidays, vacations, and when the child is not in school and therefore not eligible to be seen.
If the child is scheduled to be seen in school, please notify the therapist of upcoming field trips or if the child is absent to avoid being charged for the session.
If your child is seen on a day that is not funded by the school district, the parents are responsible and will be billed for that session.
EASTER SEALS FUNDED THERAPY SESSIONS
I agree to the following policy set:
For facility-based services, parent/caregiver is required to remain on site at the facility for the entire duration of the therapy session.
Caregivers/parents retain the right to review/revise DSLs upon request. Caregivers/parents may also revoke this permission at any time by submitting in writing.
Street shoes are not allowed on the therapy mats. Food, drinks, and cell phones are not allowed in treatment areas.
Siblings are NOT allowed in the treatment areas. Parents or other adults are not allowed to supervise any child on any Therapy West equipment. Parents are required to sit in “Parent Observation Chairs” if observing a session.
If there are other persons or professionals that would like to observe your child’s session, please notify your therapist at least 1 week before. Therapy West welcomes these visitors, but requires that a designated supervisor be present during the observation and that the visit be limited to 20 minutes.
Your signature below forms a binding agreement between Therapy West, Inc. and the Responsible Party for minor patients (those patients under 18 years old) and for patients who are receiving medical services. Responsible Party is the individual who is financially responsible for payment of medical bills.
All charges for services rendered are due and payable at the time of service.
MEDICAL INSURANCE: We have contracts with various health insurance companies and will bill them as a service to you. As the responsible party, you are responsible to pay if the services are not covered.
As the responsible party, you are responsible to pay if services are deemed “not medically necessary” and are not covered by the insurance company.
If your insurance is terminated, any services you/your child/your guardian receives after the termination of your insurance will be your financial responsibility.
If you are covered by AETNA, they have a 24 visit limitation for therapy services. As the responsible party, you are responsible for tracking the number of therapy visits/sessions that your child has received. Therapy West, Inc. is able to provide you with a visit count of services provided by Therapy West, Inc. upon request. Any visits after the 24th visit will require a prior authorization from AETNA and AETNA may choose to deny payment after the 24th visit even with the prior authorization due to "lack of medical necessity." If AETNA denies payment for services rendered after the 24th visit, responsible party is responsible for payment.
If your insurance plan has a visit limit for therapy services for the calendar year, as the responsible party, you are responsible for tracking the number of therapy visits/sessions that your child has received. Therapy West, Inc. is able to provide you with a visit count of services provided by Therapy West, Inc. upon request. Any visits provided after the visit limit will require a prior authorization from your insurance company. If your insurance denies payment for services rendered after the visit limit, responsible party is responsible for payment.
The person signing on behalf of the Patient as the Responsible Party must:
1) Inform Therapy West of the current address and phone number for the patient and the responsible party.
2) Notify Therapy West of any changes in address, phone number, insurance information or insurance coverage.
3) Pay any required co-payment/deductible/co-insurance at the time of the visit.
Returned Check Policy: If a payment is made on an account by check and the check is returned as Non-Sufficient (NSF), Account Closed (AC), Refer to Maker (RTM) or a Stopped Payment, the patient or the patients Responsible Party will be responsible for the original check amount in addition to a $35.00 Service Charge. Once notice is received of the returned check, Therapy West will send out a letter to notify the Responsible Party of the returned check. If a response is not made within 15 days from the letter date by the patient or the Responsible Party, the account may be turned over to our collection agency and a collection fee will be added to the outstanding balance – in addition to the $35.00 Check Service Charge.
Non-Payment on Account: Should collection proceedings or other legal action become necessary to collect an overdue account, the patient or the patient’s Responsible Party, understands that Therapy West has the right to disclose to an outside collection agency all relevant personal and account information necessary to collect payment for services rendered. The patient, or the patients Responsible Party understands that they are responsible for all cost of collection including, but not limited to: interest due at 18% APR, all court costs and Attorney fees and a collections fee will be added to the outstanding balance.
By signing below, you agree to accept full financial responsibility as a patient who is receiving medical services or as the Responsible Party for minor patients. Your signature verifies that you have read the above disclosure statement, understand your responsibilities and agree to these terms.
NOTICE OF PATIENT INFORMATION PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO INFORMATION. PLEASE REVIEW IT CAREFULLY.
THERAPY WEST, INC’S LEGAL DUTY
Therapy West, Inc. is required by law to protect the privacy of your personal health information (PHI), and to provide this notice about the information practices we follow.
USES AND DISCLOSURES OF HEALTH INFORMATION
Therapy West, Inc. uses your PHI primarily for treatment; obtaining payment for treatment; conducting internal administrative activities and evaluating the quality of care that we provide. For example, Therapy West, Inc. may use your PHI to contact you to provide appointment reminders, or information about treatment alternatives or other health related benefits that could be of interest to you.
Therapy West, Inc. may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, and for emergencies. We also provide information when required by law.
In any other situation, Therapy West, Inc.’s policy is to obtain your written authorization before disclosing your PHI. If you provide us with a written authorization to release your information for any reason, you may alter revoke that authorization to stop future disclosures at any time.
Therapy West, Inc. may change its policy at any time. When changes are made, a new Notice of Information Practices will be posted in the waiting room and will be provided to you on your next visit. You may also request an updated copy of our Notice of Information Practices at any time.
PATIENT’S INDIVIDUAL RIGHTS
You have the right to review or obtain a copy of your PHI at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances when we have disclosed your PHI for reasons other than treatment, payment or other related administrative purposes.
You may also request in writing that we not use or disclose your PHI for treatment, payment, and administrative purposes except when specifically authorized by you, when required by law, or in emergency circumstances. Therapy West, Inc. will consider all such requests on a case by case basis, but the practice is not legally required to accept them.
CONCERNS AND COMPLAINTS
If you are concerned that Therapy West, Inc. may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your PHI, please contact our practice manager at the address listed below. You may also send a written complaint to the US Department of Health and Human Services. For further information on Therapy West, Inc.’s health information practices or if you have a complaint, please contact the following person:
Therapy West, Inc.Janet Gunter, OTD, OTR/L
Director of Clinical Operations, Co-Owner11460 W. Washington Blvd, Los Angeles, CA 90066Telephone: (310) 337-7115
Please sign below to indicate that you have received this form and reviewed the information provided. Thank you.
I hereby give permission for Therapy West, Inc. to exchange medical, educational, psychological and/or developmental information for the purposes of treatment, payment, and/or health care operations regarding my child with the following:
I hereby authorize release of Therapy West, Inc. reports and documents relevant to the therapeutic and professional services of my child with the above-mentioned parties.
I provide consent to have my child receive therapeutic services through telehealth, Facetime, or a smartphone in the event my child does not attend a therapy session in person.
I am aware that during this session, an adult (18 years or older) must be present. The adult will also be trained in supporting my child according to their treatment plan. This session will be in lieu of an in-person visit.
Keeping an open communication between therapist and parents is important. If you have any concerns, questions, or clarifications that cannot be resolved by speaking to your therapist or a supervisor, you are welcome to contact Erna Imperatore Blanche, PhD, OTR/L, Bonnie Nakasuji, OTD, OTR/L, Dominique Kiefer, OTD, OTR/L, or Janet Gunter, OTD, OTR/L. Please help us by keeping a copy of this policy handy and by periodically updating our records.