NOTICE:

If YES, Kitestrings will call you to obtain payment information. 

If NO, payment by credit card is available without autopay by requesting a secure link from Kitestrings. Email info@kitestringstherapy.com to request monthly secure links to be sent. 

• Payments are due within 15 days of the date of the invoice, mailed to you monthly.
• Therapy will be placed on hold if a payment is more than 60 days late.
• Payments later than 60 days will incur a $50.00 late charge per month.
  (Your therapist receives payment for their services only after your payment is received thus timely payments are very
  important).
  
  

• I authorize this office to provide therapy service to me on a private pay basis.
• I acknowledge that the purpose, process, and estimated cost for this service have been explained to me by Kitestrings Pediatric Therapy. Because my insurance does not cover this service, I agree that I am responsible for the amount due within 15 days of statement date. Should a discount be applied, I further understand that this discount may be removed if the balance due is not paid within the above stated time frame.
• I agree that I have chosen this service on a private pay basis and I waive the right to have any insurance filed by the practice on my behalf. I also agree that no insurance discounts may be applied towards this debt.

We are honored that you chose Kitestrings Pediatric Therapy for your child. To get the most effective and efficient therapy, your therapist establishes a treatment plan with recommended therapy visits. Your therapist reserves an appointment time specifically for your child. Please make every effort to make this appointment.

Cancellations, especially last-minute ones, along with no-shows, decrease our ability to accommodate the scheduling needs of other patients and impact your child’s progress in therapy. Advance notice allows us to offer the appointment to another client who may need to make up an appointment and notifies the therapist not to prepare for your session. We understand that from time to time you may need to cancel a therapy session due to emergencies, illnesses or other unexpected conflicts. We ask you to respect the following attendance and cancellation policy:

1. Please notify your treating therapist 24 hours before the scheduled treatment session. Each therapist keeps her own schedule so it is best to agree upon the best form of communication before initiating therapy.

2. In the event that you do not notify your therapist 24 hours in advance to cancel your appointment, it will be recorded as a NO SHOW and charged a $50.00 no show fee. This fee is not billable to insurance and must be paid by you. Note: this fee will be waived in the event of contagious illness (we ask that your child be symptom free for 24 hours before coming in for therapy). Unexpected emergency events will be considered for a fee waive at the discretion of your treating therapist.

3. After Three NO SHOW appointments the fourth and future no shows will be charged at the full private pay rate and may result in dismissal from your current therapy schedule at the discretion of the treating therapist.

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.

OUR RESPONSIBILITIES
Kitestrings Pediatric Therapy is required by law to:
• Maintain the privacy of your health information
• Provide you with a copy of this Notice describing our duties and privacy practices as to the information we collect and maintain about you
• Abide by the terms of our current Notice
• Accommodate reasonable requests to communicate with you about your health information

      We reserve the right to change, amend or eliminate provisions in our privacy practices and to make the new provisions effective for all health information we keep. Should our privacy practices change, we will amend our notice. You are entitled to receive a copy of the amended notice by calling and requesting a copy of the amended notice or by visiting our office and picking up a copy. We will not use or disclose your health information without obtaining a signed authorization from you except as described in this Notice or as otherwise permitted or required by law; for example, in emergency treatment situations.

HOW WE MAY USE AND DISCLOSE YOUR PERSONAL HEALTH INFORMATION
• For treatment: We may use your health information to provide you with healthcare treatment and to coordinate services with other healthcare providers such as your referring physician. We may disclose your health information to family members and friends, guardians or personal representatives who are involved with your medical care. We may also use your health information to contact you for
appointment reminders. We may also disclose your healthcare information to people outside the
facility who may be involved in your healthcare after you leave our facility.
• For payment: We will use and disclose your health information to receive payment for our services and determine insurance coverage. We will also use your health information for billing, collection, claims, and medical data processing. We will use and disclose your health information to business associates that we have contracted to perform agreed upon services i.e. billing services and accountant.
• For Healthcare Operations: We may disclose your healthcare information for routine operations in this clinic, such as business planning and development, quality review of services provided, licensing or credentialing activities, certification, internal auditing, accreditation, and education for staff.
• For Research: We may use your information for research purposes subject to special approval by you.
• For Video/Audio Recording: For evaluations and therapy, the therapist might need to record the session. This is required so the therapist can review information once the session is completed. This information will be used by Kitestrings Pediatric Therapy staff only.
• For emailing: Some parents wish to communicate via email. If you give us your email address, you are consenting to communicating via email.
• Serious Threat to Health or Safety: We may disclose your health information when necessary to prevent a serious threat to your health and safety or the health and safety of another person or the public. We may use or disclose health information about you without your prior authorization for several reasons. Subject to certain requirements, we may give your health information about your without your prior authorization for public health purposes, abuse or neglect reporting, health oversight audits or inspections, medical examiners, funeral arrangements, organ donation, workers’ compensation purposes, emergencies, national security and other specialized government functions. We also disclose health information when required by law, such as in response to a request from law enforcement in specific circumstances, or in response to valid judicial or administrative orders or other legal process, such as court order or subpoena.

Your Rights Regarding Your Health Information
• You may request a copy of summary of your health information or you may inspect it. If you request a copy, we may charge a fee for the cost of copying and mailing associated with the request. Texas law allows fifteen days for us to complete your request. We will inform you when records are ready. If we deny your request, we will do so in writing.
• You may request an amendment to your health information if you feel there is an error.
• You have the right of refusal to sign an authorization and it not be held against you.
• You may change your mind and revoke your authorization, except where actions have already been taken by us relating to that authorization. Requests must be made in writing and submitted to the privacy officer at Kitestrings Pediatric Therapy.
• You have the right to an accounting of all entities with whom we have shared or disclosed your health information unrelated to treatment, payment, or healthcare operations.
• You may request a restriction on certain uses of your health information (we will consider reasonable, appropriate requests but are not obligated to agree to them).
• You have the right to obtain a paper copy of this Notice of Privacy Practices.
• You may file a complaint if you believe that your privacy rights have been violated.

Any requests or other communications about the rights listed above should be directed to: Kitestrings Pediatric Therapy Privacy Officer at 512-261-3584 or 1202 Lakeway Drive, Suite 6A, Lakeway, TX 78734 or to the Secretary of the Department of Health and Human Services, 200 Independence Avenue SW, Washington DC 20201.
We reserve the right to change this notice. The revised or changed notice will be effective for the information we have about you as well as any information we receive in the future.

I understand that telepractice is the use of electronic information and communication technologies by a licensed therapist to deliver services to an individual that is located at a different site than the provider; and hereby consent to Kitestrings Pediatric Therapy providing care services to me via telepractice.

I understand that the laws that protect privacy and confidentiality of medical information also apply to telepractice. As always, you insurance carrier will have access to your medical records for quality review/audit.

I understand that I will be responsible for any copayments, coinsurances, or self-pay rate that apply to my telepractice visit.

I understand that I have the right to withdraw or withhold my consent to the use of telepractice in the course of my child’s care at any time, without affecting my right to future care or treatment. I may revoke my consent orally or in writing at any time by contacting Kitestrings Pediatric Therapy at 512-261-3584.

As long as this consent is in force (has not been revoked), Kitestrings Pediatric Therapy may provide services to me via telepractice without the need for me to sign another consent form.

General Office Procedures:
• Our office does not have a waiting room; therapists will either pick up and return
children to their cars or will communicate with the caregiver regarding entry into the
office.
• Only one caregiver may accompany/observe their child in therapy (no siblings allowed in
the clinic).
• Therapists and adult caregivers will wear masks.
• We always encourage children to wear masks, understanding a few young children may
not tolerate this which we will take into consideration.
• Social distancing will be maintained as much as possible.
• Treatment areas sanitized/disinfected in between each session.

Client Procedures
• Sign and agree to COVID 19 safety procedures and waivers
• Wait in car (do not enter clinic) at time of appointment for therapist to retrieve client or
to notify caregiver of entry.
• Any adult and/or child entering the clinic must answer safety protocol questions each
day at clinic:
o Wash hands immediately upon entry to clinic
o Take temperature (if 100.4 or above will cancel, go home to seek medical advice.)
o Answer “NO” to all COVID 19 Health safety questions (if yes, they will discuss
with their therapist so that a determination of appointment status can be made
based on current CDC guidelines)
• Child may bring own toys to use in therapy if parents prefer.

Therapist Procedures
• Complete safety protocol each day at clinic:
o Wash hands immediately upon entry to clinic
o Take temperature (if 100.4 or above therapist will cancel and go home to seek
medical advice)
o Answer “NO” to all COVID 19 Health safety questions (if yes, they will follow
current CDC guidelines for COVID19):
• Wear mask during session
• Perform therapy in room with materials pulled only for that child. Upon completion of
therapy, complete sanitizing/disinfecting of any materials used, or items touched.
• Maintain social distance from other at office as best as possible.

Kitestrings Pediatric Therapy has put in place these preventative measures to reduce the spread of COVID-19 due to and in compliance with recommendations from the World Health Organization, Centers for Disease Control (CDC), federal, state, and local government which state that COVID-19 is a highly contagious worldwide pandemic, spread mainly from personto-person contact. However, Kitestrings cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending Kitestrings could increase your risk and your child(ren)’s risk of contracting COVID-19.

NOTICE
By signing this agreement, I acknowledge and understand the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may take by attending therapy at Kitestrings and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at Kitestrings may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Kitestrings staff, and therapy participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at Kitestrings or participation in Kitestrings therapy. On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless Kitestrings, its employees, agents, and representatives, of and from all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any claims based on the actions, omissions, or negligence or gross negligence of Kitestrings, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Kitestrings therapy.

COVID-19 Response Plan: VACCINATED PERSONS

      We ask clients and therapists to please notify Kitestrings if they test positive for COVID-19. Kitestrings will determine the last time the positive person was at Kitestrings, close off areas used, per CDC guidelines wait 24 hours to disinfect, and notify anyone who was in close contact* with that person (confidentiality of individual will be maintained).  Potential exposure is minimized due to our strict protocols of only 1 child/parent : 1 therapist allowed in close contact (with personal protective equipment).

Notify your healthcare provider of any symptoms, known, or suspected exposure to COVID-19.

Return to Clinic/Therapy may occur by:

1. Following appropriate CDC response OR
2. Proof of Negative COVID-19 test from approved testing location (https://tdem.texas.gov/covid-19/) at least 48 hours after known or suspected exposure

*alternate medical diagnosis from a doctor will be considered on a case by case basis (e.g. chronic allergies).

Situational CDC Response Breakdown: 
Positive COVID-19 test or positive diagnosis with symptoms
ISOLATE* until:

• At least 5 days since positive test first appeared, continuing to wear a mask for an additional 5, AND
• At least 24 hours with no fever without fever-reducing medication, AND
• Symptoms are resolving
• If symptomatic after 5 days, isolate for 10 days

Positive COVID-19 test or positive diagnosis with NO symptoms
ISOLATE until:

• 5 days have passed since test, continuing to wear a mask for 5 days
• If symptoms develop, follow above response (Positive COVID-19 test or diagnosis with symptoms)

Negative COVID-19 test with symptoms (no known exposure)

• STAY HOME until symptoms have improved and are fever free for 48 hours without the use of fever-reducing medication
  Fully vaccinated people with COVID-19 symptoms
   
  Although the risk that fully vaccinated people could become infected with COVID-19 is low, any fully vaccinated person who experiences symptoms consistent with COVID-19  should:
  • Isolate themselves from others
  • Be clinically evaluated for COVID-19, and tested for SARS-CoV-2 if indicated. (The symptomatic fully vaccinated person should inform their healthcare provider of their vaccination status at the time of presentation to care.)

Known or suspected exposure (close contact) no symptoms
Fully vaccinated people who have come into close contact* with someone with COVID-19 should

• Be tested 5 days following the date of their exposure and wear a mask in public indoor settings for 10 days
• Isolate if they test positive. (Fully vaccinated people who live in a household with someone who is immunosuppressed, at increased risk of severe disease, or unvaccinated (including children
• Most fully vaccinated people with no COVID-like symptoms do not need to quarantine or be restricted from work following an exposure to someone with suspected or confirmed COVID-19, if they follow the testing and masking recommendation above.
• Fully vaccinated people should monitor for symptoms of COVID-19 for 10 days following an exposure.
  Fully vaccinated people with no COVID-19-like symptoms and no known exposure to someone with suspected or confirmed COVID-19
   
  It is recommended that fully vaccinated people with no COVID-19-like symptoms and no known exposure should be exempted from routine screening testing programs, if feasible.

COVID-19 Response Plan: UNVACCINATED PERSONS (Or adults 6 months post second shot with no booster)

       We ask clients and therapists to please notify Kitestrings if they test positive for COVID-19. Kitestrings will determine the last time the positive person was at Kitestrings, close off areas used, per CDC guidelines wait 24 hours to disinfect, and notify anyone who was in close contact with that person (confidentiality of individual will be maintained).  Potential exposure is minimized due to our strict protocols of only 1 child/parent : 1 therapist allowed in close contact (with personal protective equipment).

*Notify your healthcare provider of any symptoms, known, or suspected exposure to COVID-19.

Return to Clinic/Therapy may occur by:

1. Following appropriate CDC response OR
2. Proof of Negative COVID-19 test from approved testing location (https://tdem.texas.gov/covid-19/) 5 days after known or suspected exposure

*alternate medical diagnosis from a doctor will be considered on a case by case basis (e.g. chronic allergies).

CDC Response Breakdown: 
Positive COVID-19 test or positive diagnosis with symptoms
ISOLATE until:

• At least 10 days since positive test,  AND
• At least 24 hours with no fever without fever-reducing medication, AND
• Symptoms have improved

Positive COVID-19 test or positive diagnosis with NO symptoms
ISOLATE until:

• 10 days have passed since test or 5 days if able to wear well fitting mask
• If symptoms develop, follow above response (Positive COVID-19 test or diagnosis with symptoms)

Negative COVID-19 test with symptoms (no known exposure)

• STAY HOME until symptoms have improved and are fever free for 48 hours without the use of fever-reducing medication

Known exposure (close contact) no symptoms

• Quarantine for 5 days after last contact with person with COVID-19, take a test after 5 days, continue to wear a well-fitted mask for 5 days
• If unable to mask, quarantine for 10 days
• Monitor health for symptoms of COVID-19, avoid contact with others

Suspected exposure (close contact) no symptoms

• Quarantine for 14 days after last contact with person with COVID-19
• Monitor health for symptoms of COVID-19, avoid contact with others 

Defined:

•   Close contact : within 6 ft of a COVID-10 infected person for at least 15 minutes, during the 48 hours before the person began feeling sick until the sick person began isolation (even if a mask was worn).
• Quarantine: helps prevent spread of disease that can occur before a person knows they are sick or if they are infected with the virus without feeling symptoms.  Involves staying home for 14 days, separate from others, monitor health, and follow state and local health department guidelines.
• Isolate: separates people infected with COVID-19 from people who are not infected.  Involves staying home, separate from others by staying in a specific “sick room” or area and separate bathroom if possible.

• I have read, understood and agree to the stated policies and agreements.
• I hereby certify that, to the best of my knowledge, the provided information is true and accurate. 
• I acknowledge that this Agreement will automatically be renewed
  and will continue for future Service Years unless I notify Kitestrings Pediatric Therapy of my intention to terminate.
• I acknowledge that either I or Kitestrings Pediatric Therapy may terminate this Agreement at any time upon 30 days written notice. If either party terminates this Agreement, any final balance due will be charged by the method on file within the 30 day period.