• Client Information

    Please fill out the following sections: Contact and referral information, birth, medical and developmental history, and concerns/goals for therapy.
    • Client Information 
    • Primary Contact 

    • Secondary/Emergency Contact

    • Referral Information 
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    • Birth & Medical History 
    • Client's Developmental History 

    • Speech, Language & Communication Development

    • Motor Development

    • Educational History 
    • Concerns/Goals for Therapy 
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  • Kitestring's Payment Agreement

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  • NOTICE:

    If YES, Your first invoice will be emailed to you. To enroll in autopay, please pay your first bill with the credit card you would like to use for autopay, and be sure to select "Save my card on file." Kitestrings will then be able to run your card automatically and send you a mailed receipt monthly. 

  • NOTICE:

    Switch to autopay at anytime. Simply email info@kitestringstherapy.com a request, and we will email your next invoice to you. Then, to enroll in autopay, please pay the invoice with the credit card you would like to use for autopay, and be sure to select "Save my card on file." Kitestrings will then be able to run your card automatically and send you a mailed receipt monthly.

  • Payment Information

    • 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).

  • Private Pay

    • 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.

     

  • Bill Insurance

    • I have engaged Kitestrings Pediatric Therapy to provide therapy services for my child.
    • I have been informed that as with any claims submitted by the healthcare provider, my health plan may deny payment for services.
    • I understand that if the health plan denies payment, or there is a balance due after insurance, I agree to be personally and fully responsible for payment of the services rendered.

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  • Provider's Notice:

  • Some health insurance plans will only pay for services that they determine to be “reasonable and necessary.” If an insurance plan determines that a particular service, although it would otherwise be covered, is “not reasonable and necessary”, the insurance plan may deny payment for that service. Please know that we will make every effort to collect the amounts due from the insurance provider, including following any appeals process that the provider has in place for collection of these claims.

  • Policyholder Patient Agreement


  • I ,   *   *   , have been informed on this date   Pick a Date*   by my therapy provider (and/or staff) that, as with any claims submitted by the healthcare provider, that my health plan may deny payment for the services I am pursuing at Kitestrings Pediatric Therapy. I understand that if the health plan denies payment, I agree to be personally and fully responsible for payment of the services rendered. I also understand that I may have a deductible that must be met before insurance will begin paying Kitestrings Pediatric Therapy. It is my responsibility to know my deductible and understand that I am fully responsible for payment of these charges for services rendered.

  • Kitestring's Cancellation Policy

  • 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.

  • Kitestring's Consent for Therapy Services

  • Consent to Evaluate

  • I give Kitestrings Pediatric Therapy permission to evaluate my child   *   *   , date of birth   Pick a Date* . I understand that the results of the evaluation are confidential and will not be released without my written authorization (other than HIPAA approved persons/organizations).

  • Consent to Communicate

    Please indicate your preferred methods of communication between you and Kitestrings. NOTE: When you select text and email you acknowledge these are not secure forms of communication and there is some risk that some personal health information (PHI) may be disclosed to, or intercepted by, unauthorized third parties

  • Release of Information

    I authorize an exchange of information between Kitestrings Pedicatric Therapy and the agencies and/or personnel listed below. I understand that I have the right to revoke this authorization at any time. This authorization is optional and will not ipact the treatment my child receives.
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  • Kitestring's Privacy Practices (HIPAA Compliance)

  • 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.

  • Kitestring's Telepractice Informed Consent

  • 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.

  • Kitestring's General Health Guidelines:

  • Kitestrings Pediatric Therapy will follow CDC and/or Austin-Travis County health guidelines.  

    Please monitor your child’s health for signs of illness, including fever, cough, sore throat, headache, congestion, nausea, diarrhea, and vomiting.  If your child is displaying any of these symptoms or other signs of illness, we ask that you cancel or reschedule your appointment.

    If your child has received a positive COVID-19 test or is awaiting the results of a COVID-19 test, please cancel or reschedule your appointment.
    We encourage handwashing/sanitizing upon entry into the clinic.

    Masks are optional for patients, caregivers, and therapists at this time.  You will be notified if this policy changes.

  • Kitestring's Assumption of the Risk, Waiver and Release of Liability relating to Coronavirus/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.

  • PLEASE READ AND SIGN

    • 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.
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