HIPAA CONSENT FORM

Purpose: This notice explains the privacy practices of Children in Motion, it’s providers, trainee’s, and volunteers.

Value: Children in Motion values each client’s right to privacy, respect, and dignity.

Notice: Children in Motion is required by law to provide you with information about how we ensure your privacy and the security of your personal information and health data.

Children in Motion will:

1) Notify you as soon as possible if your personal or health information is compromised in any way.

2) Will follow the terms of this agreement and will provide you a copy of this agreement upon your request at any time.

Children in Motion use your information in the following ways:

1) Treatment: Your health information may be shared within our organization/company in order to provide you with the best, most comprehensive, treatment possible. We may use your health information to make recommendations for other beneficial treatments, equipment, or alternative services that may promote your progress.

2) Billing and Compensation for Services: Children in Motion uses and shares your health information to bill and receive compensation for services rendered by our company and it’s employees.

3) Clinic Management: Children in Motion will use your personal information to contact you when necessary regarding appointments, billing, or other concerns related to your therapy services. Your personal information may also be shared with third parties for assistance with billing, treatment, or other administrative needs. Any third party receiving your information adheres to all of the Privacy Policies as set forth by Children in Motion.

4) Mandatory Reporter Laws: Therapists and Employees of Children in Motion are considered Mandatory Reporters. This means that they may use your personal information if abuse, neglect, or domestic violence are suspected. Additionally, our employees and volunteers must report intent to harm self or others to the proper state organization.

5) To Comply with the Law: Your information will be shared as required by state and federal laws. This may include sharing information with the Department of Health, formal requests by law enforcement agencies; state, and federal health oversight agencies, and in response to a court or administrative order for lawsuits and legal actions.

Any other way that your information is shared must meet a multitude of conditions under HIPAA Laws.

The terms of the notice may change at any time. If so, you will be notified at your next visit to update your signature/date.

Client and Patient Rights Under HIPAA

Under HIPAA you have the right to the following:

1) Obtain a copy of this notice

2) Request a copy of your full electronic medical record including therapy evaluations, treatment notes, and billing records. There is a fee of $0.10/Page for printed copies of your medical record. All evaluations and treatment notes are available on our Patient Portal free of charge.

3) Request changes to your record: You have the right to request a correction to your medical record if you believe there is information which is erroneous or incomplete.

4) Request Confidential Communication: You may request to have us communicate with you through a different phone number or through other means.

5) You have the right to request restriction of how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction and may say “no” if we believe it will impact your therapy services. If you request to pay for therapy sessions 100% out-of-pocket/cash pay, you may request that we do not share your personal or health information with your insurance company. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

6) Be notified if there is a breach of your personal or health information. If this occurs, you will receive notification in writing about the breach with instructions and required information.

7) Receive a list of anyone with which your information has been shared. You may make this request through our front desk, in writing for up to the past 6 years of services.

8) Choose a Medical Power of Attorney or Legal Guardian to make medical and health decisions for you. Documentation of this choice is required for Children in Motion to comply with your choice.

If you have concerns regarding your personal information, please contact our front desk at (801) 871-5492 or request to speak with our operating manager at the front desk. You may also file a complaint with the Office of Civil Rights at the U.S. Department of Health and Human Services.

CLINIC POLICIES

Purpose: To provide clear expectations for successful occupational therapy services on the part of the provider and the client.

Value: We believe that consistent attendance to therapy sessions each week is crucial to a person’s progress. We believe in ensuring that all our staff and clients can be safe, happy, and healthy. We believe in respect, family, and caring for others.

Parent Engagement: For pediatric clients, parent engagement and follow-through at home is imperative to your child’s progress and success. Therefore, unless otherwise recommended by your therapist, 1 parent is expected to be present for all therapy sessions.

Present is defined as being in the therapy room interacting with your child and the therapist to improve your skills and your child’s skills.

Child Supervision Policy: Because Children in Motion is not a day-care provider, we are not licensed under the City of Murray to have children on the premises without a parent present. Therefore, all children under the age of 16 years are required to be accompanied by a parent or adult guardian (over the age of 18 years) at all times.

Children must also be accompanied to the restrooms by a parent or guardian, without exception. Any child on the premises of Cedar Park Office Complex, must be directly supervised by a parent or adult guardian at all times.

Weather and Emergencies: In the case of heavy snow or weather concerns, Children in Motion will follow Salt Lake and Murray School District closures. If either Salt Lake or Murray School Districts are closed, Children in Motion will also close.

COOPERATION AND BEHAVIOR: You agree to conduct yourself in a manner that is appropriate for a setting where children are regularly present.

Additionally, you agree to avoid actions and behaviors that may cause injury to other clients, staff, and any affiliates of Children in Motion.

You agree to not threaten the safety of any person at or affiliated with Children in Motion.

Finally, you agree that inappropriate, threatening, or unsafe behaviors may result in discontinuation of your or your child’s services.

Children in Motion is not a behavioral intervention clinic. Therefore, children who are physically aggressive or have a history of injuring others may be referred to more appropriate settings and organizations.

NON-DISCRIMINATION: Children in Motion does not discriminate against any person on the grounds of race, gender or gender identity, ethnicity, color, religion, sexual orientation, age, disability, or socio-economic status regarding provision of therapeutic services and participation in therapeutic services.

Children in Motion does not tolerate or allow discrimination for any reason against its staff, employees, or students by any visitor, client, or client’s family members.

CONSENT FOR TREATMENT AND FINANCIAL AGREEMENT

Purpose: To inform clients and families of their responsibilities and rights as patients/clients of Children in Motion.

Value: Children in Motion values the open sharing of information and clarity for clients around their rights and responsibilities as a client.

CONSENT FOR TREATMENT: I (Parent/Guardian of Client) give consent for myself or my child to receive therapeutic services (i.e. occupational therapy, physical therapy, speech language pathology) with Children in Motion’s employees,staff, or intern students.

Your care may involve inter-professional communication between therapists in the department to benefit your therapeutic outcomes and to provide the highest quality of care possible.

Our employees participate in weekly mentoring in which your care may be discussed for the purpose of providing high quality care.

By signing this agreement, you understand there are inherent risks of participating in therapeutic activities at Children in Motion.

You agree that no one has made any guarantees regarding the result of your treatments at Children in Motion, as rehabilitative therapies are not an exact science.

2. CONSENT FOR STUDENT OBSERVATION AND INTERN PARTICIPATION: As a Client of Children in Motion, you understand that one of the missions of Children in Motion is to promote continued growth and success for Occupational Therapy,Physical Therapy, and Speech Language Pathology.

As such, Children in Motion does engage Interns from national university graduate programs for completion of their internships and fieldwork. All students are fully supervised during treatment sessions and all sessions are developed under the direct supervision of the supervising therapist.

Additionally,Children in Motion allows prospective students to earn observation hours by observing therapy sessions in our clinic.

All students engaged with our clinic are required to sign a confidentiality agreement and adhere to HIPAA Privacy Practices.

3.FINANCIAL AGREEMENT: You are ultimately responsible for your bill in its entirety. Payment of all bills are due upon receipt.

Per Utah law, Children in Motion may pursue payment from both parents of a minor child for payment of theminor child’s therapy bills.

By signing this agreement, you authorize Children in Motion, or its collection agents, to call or text you for the purpose of scheduling, billing, payment, or other concerns regarding your treatment.

You agree to be held responsible for any collection’s fees related to unpaid invoices and charges.

You agree to pay any fees and charges you incur as part of your treatment at Children in Motion.

It is the parent/guardian’s responsibility to understand their insurance coverage, co-payments, deductibles,and out-of-pocket maximum.

It is recommended that you call your insurance company prior to starting therapy services to review this information and understand your financial responsibilities and benefits.

Per Federal and State laws, Children in Motion does not balance bill.

Cash pay clients, or out of network clients, may qualify for a discounted rate. Please speak with our front office staff or our billing office to request more information.

4. ASSIGNMENT OF BENEFITS AND INSURANCE: By signing this agreement you confirm that the information you have provided to Children in Motion to apply for payment from any health insurance company iscorrect and complete. You authorize any insurance, health plan, statutory benefits, settlements, and judgements related to your therapy services to be paid directly to Children in Motion. Additionally, you assign all insurance benefits related to your treatment to Children in Motion for any unpaid balances. You agree that you are financially responsible for all care provided to you or your child by Children in Motion.

5.DUAL CUSTODY SITUATIONS: By signing the agreement, if you share custody of the client listed above with another adult, you are stating that you have the legal right to seek therapeutic services for yourchild.

In cases of dual custody, the court may require both parents to sign this agreement and seek therapy services for the client listed above. It is your legal responsibility to know if you can legally seek therapeutic services without the consent of the other party.

By signing this agreement, you are stating that you agree to the terms within this document. You have received a copy of this document and have the legal authorization to accept these terms on behalf of the client.

By signing this document, you are stating that you have legal medical and therapeutic rights to seek therapy services and treatment for the child.

This notice you are receiving is on behalf of your provider and Children in Motion, LLC. When you are treated by an out-of-network provider you are protected from surprise billing or balance billing.

What is Surprise Billing or “Balance Billing?”

-When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment,coinsurance, and/or a deductible. You may have other costs or must pay the entire bill if you see a provider or visit a healthcare facility that isn’t in your health plan’s network.

-Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay, and the full amount charged for a service. This is called “balance billing.” This amount is may be more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

-“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit and are unexpectedly treated by an out-of-network provider.

Your Rights and Protections from Balance Billing

RECEIVING SERVICES AT AN IN-NETWORK THERAPY CLINIC

-When you get services from an in-network therapy center, certain providers there may be out-of-network. In these cases,the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine,anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

-If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

-You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When Balance Billing Is Not Allowed

YOU ALSO HAVE THE FOLLOWING PROTECTIONS:

-In the case of Balance Billing, you are only responsible for paying your share of the cost (like the co-payments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly in these situations.

Your health plan generally must:

-Cover emergency services without requiring you to get approval for services in advance (prior authorization).

-Cover emergency services by out-of-network providers.

-Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.

-Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

Children in Motion currently is currently “In-Network” with the following insurance companies:

-Select Health – All Plans Including Community Care

-Regence Blue Cross/Blue Shield (*Some Plans may be Excluded, Please check your plan)

-University of Utah Health Plans – All Plans including Healthy U.

-Molina Health Care

-Utah State Medicaid

Children in Motion requires all clients to keep an active credit card on file. Your Credit Card Information is kept confidential and secure on our Electronic Medical Record System.

FOR INSURANCE CLIENTS: Payments will be processed for Co-Pays at the time of service. After the claim has been filed and processed by your insurer, the amount your insurance company deems your responsibility will be charged to your card.

Charges for “no show” or “late cancel” will be charged at the rate of $50 per occurrence, as outlinedin our Clinic Policies.

You will be notified via email when your card has been charged for services or fees.

FOR CASH PAY CLIENTS: Payments will be processed for services rendered within 48 hours of your session.

Charges for “no show” or “late cancel” will be charged at the rate of $50 per occurrence, as outlined in our Clinic Policies.

You will be notified via email when your card has been charged for services rendered.

NOTICE OF NO SURPRISES ACT

Your Rights and Protections Against Surprise Medical Bills

I have been provided with a copy of Children in Motion’s No Surprises Act Notification.

I understand that it is my responsibility to ensure that Children in Motion, Rhonda Roth, and/or the treating therapist is an In-Network Provider for my Insurance Plan.

I understand that if Children in Motion is not an In-Network Provider with my insurance company, I have the option to select the Cash Pay Rate or to seek Occupational Therapy Services with an In-Network Provider instead of with Children in Motion.

I understand that I am solely responsible for all Co-Pays, Deductibles, Co-Insurances, or other charges my insurance company deems to be my responsibility.

I understand that if I select Cash Pay Rates my credit card on file will be charged within 48-hours of services rendered.

Please keep in mind that when you miss a session, your child, your therapist, and our clinic are impacted.

We hold a spot each week specifically for your child. Therefore, high cancellation rates impact our clinic significantly and may impact your therapist financially in the long term.

Unlike many other clinics, we pay our therapists even if you do not attend the session. When you pay a cancellation fee, the money goes directly to paying your therapist for the spot we had held for your child that day. Children in Motion makes no profit off of your cancellation fee.

As of November 1, 2023:

1) At least 24-hours notice of any cancellation is now required. Any cancellation of less than 24-hours notice, including all no-shows, will be charged a $50 fee, for the first occurrence.

2) A second occurrence of a no-show, or late cancellation of less than 24-hours, will result in a fee of $100 and the client may be moved back to our waiting list.

3) All families are required to keep an active credit card on file. If your account is not in good standing 24-hours prior to your next session, your next appointment will be cancelled and your child may be moved to the waitlist.

4) If your child is not able to attend at least 3 sessions within a month, we will not be able to hold that spot for your child. This includes any two cancellations made within the same month.

When your family is able to consistently attend therapy sessions, please contact our office and we will do our best to get you back on the schedule as soon as possible.

5) For Vacations or School Breaks (i.e. Spring Break, Winter Break, Thanksgiving Week, Summer Break, etc.): We want to support families in taking time for themselves and relaxing. Please provide at least 1-weeks notice if you know you will be out of town or missing one session. If you will be missing more than 1 session in a month, we will not be able to hold your spot. We will do our best to get you back on the schedule as soon as possible when you return from your travels. Please call our scheduling line when you return to see what appointment times are available.

5) If your therapist is sick, we will call you by 8 am. We will do our best to schedule a make up session if possible for these missed days. We apologize for any inconvenience if our therapists are sick or have a family emergency. We do ask therapists to stay home if they are ill so they do not get our other staff sick and to limit exposure to our clients who have more significant medical needs. If another therapist is available to fill in for your therapist, you may be assigned a different therapist for the same day.

6) If your child is sick, please do not bring them to therapy. For stuffy/runny noses, coughs and colds (Without a fever), please have your child wear a mask and wash their hands before they come into the therapy session.

Q1) Why am I charged $50 if I cancel my appointment or if I no show to my appointment?

A1) Children in Motion values our therapists and their ability to support their families and to make a good living wage.

Additionally, we value consistent therapy times and days for our clients.

Therefore, we hold a therapy spot each week, on the same day and time specifically for your child’s therapy session.

Your therapist spends a lot of time planning and preparing for your session. If you do not attend your session as planned, your therapist is still paid for that time.

In order to keep our pay competitive for our staff, and keep our clinic open, we charge clients for Late-Cancellations or No-Show sessions.

Q2) I just do not feel we are clicking with our current therapist. What should I do?

A2) At Children in Motion, we believe that your relationship with your therapist is paramount to your child’s progress. If you are not clicking with your current therapist, that is okay! Please give our office administrator a call and they will work with you to see if a different therapist on our staff might be a better fit.

Not loving Children in Motion? While that makes us sad, that is okay too. We know we are not the right fit for every family.

Please let us know and we are happy to recommend other clinics in the area that might be a better fit.

You can always contact our CEO via voicemail at (385) 276-2032 or via email at Rhonda@Children-in-motion.com