______
Child’s Name
Kidz Therapy Services, PLLC
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 Policy.
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
Attendance
ÿ I agree to have another therapist cover my child’s session.
ÿ I do not agree to have another therapist cover my child’s session.
Confidentiality
ÿ I agree to allow my child’s therapist to discuss his/her progress in the waiting room. I am aware by doing this I waive my right to confidentiality.
ÿ I do not agree to allow my child’s therapist to discuss his/her progress in the waiting room and will use a communication notebook.
______FOR OFFICE USE ONLY:
ÿ Acknowledgement Form ÿ Email Consent Form
ÿ Waiting Room Policy ÿ Consent to Talk to Teacher
ÿ Sick Child Policy ÿ Allergy Form: ______
ÿ Emergency Information Form ÿ Medicaid Parental Consent Form
ÿ Rx: ÿ ST ÿ OT ÿ PT
Welcome at 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. If you miss 3 consecutive sessions or more than 25% of the scheduled sessions in any month your appointment time is not guaranteed. For example, if your child receives therapy 2 x 30 weekly, and is absent for 2 sessions without receiving make-ups within that month, we will contact you regarding a change of provider or time. Please inform us of any medical or family emergencies so other arrangements can be made. Kidz Therapy reserves the right to cancel these services at their sole discretion.
-If you are unable to keep your child’s scheduled appointment, you must contact KIdz Therapy’s office prior to your appointment. Do not call your therapist as they may be treating another child. If your child’s session is cancelled for whatever reason, your child’s therapist will contact you prior to your next session to schedule a make-up session if their schedule permits. Group sessions cannot be
made up.
-Please attempt to arrive 10 minutes before your scheduled session. This will allow for a smooth transition into therapy.
-Make-ups must occur within two weeks of the missed session. Only one make-up session per week is allowed. The same service cannot be provided two times in one day even if your child has two different therapists (no make-ups 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 therapist schedule permits.
-If your child’s OT, PT or ST is absent your child may be seen by another therapist only if another therapist is available. You will be notified as early as possible prior to your child’s session. Indicate your preference on the Parent Acknowledgement form.
-You or a designated caregiver (18 years or older) must be on site at all times while your child is receiving therapy.
-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.
Therapy Specifics
-Discussion of your child’s progress is considered an essential part of the therapy process. Therefore, all therapy sessions will allow for direct intervention and parent/guardian consultation within the allotted therapy time. For example, a 30-minute session allows for 25 minutes of direct therapy and 5 minutes for parent consultation. Formal reviews of progress reports or annual reviews will take place during your child’s regularly scheduled session time if necessary.
-Occupational and physical therapy cannot begin until a doctor’s prescription is obtained.
-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.
Fire Drill
In case of a fire drill, all children will be escorted to the nearest exit by their treating therapist. Parents should exit the waiting area to the right down the hall to the stairway. You will meet your child outside in the front of the office building. Leave strollers in the waiting room as they are a hazard in the stairwells for all occupants of the building.
Confidentiality
-Due to Federal regulations regarding confidentiality, you will be provided with a choice of providing a communication notebook for the therapist(s) to use or waiving your right to confidentiality by allowing us to speak with you or your designated caregiver in our waiting room. More detailed discussions can be scheduled as part of your child’s treatment session per your request. Indicate your preference on the Parent Acknowledgement form.
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.
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 therapy services (speech, occupational therapy, physical therapy) on a different day during that week. Keep in mind that typically our therapists see up to 11-13 children per day so their unscheduled time is very limited. 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 you have any questions regarding attendance please feel free to contact us.
Sincerely,
______
Judy Mahoney, MA, CCC-SLP Donna Menna ED, MA, CCC-SLP
Clinic Director-Nassau Clinic Director-Suffolk
NASSAU COUNTY
DEPARTMENT OF HEALTH
OFFICE OF CHILDREN WITH SPECIAL NEEDS
Preschool Special Education Program
60 Charles Lindbergh Blvd. Suite 100, Uniondale, New York 11553-3683
Dear Parent/ Guardian of ______:
Is your child Medicaid eligible and/or receiving SSI Benefits? ( ) Yes ( ) No
This is to ask your permission to bill Medicaid for Medicaid reimbursable services that are on your child's individualized education program (IEP). Schools in New York State routinely access Medicaid funding to help meet costs of providing special education services. Please sign below.
I, ______as the Parent / guardian of
______DOB ______,
(Print child’s name)
give permission for the school district / municipality to use Medicaid to pay for special education services rendered on behalf of my child for all Medicaid eligible services listed on my child’s IEP dated: ______.
I understand that the use of Medicaid insurance for special education services will not decrease the available lifetime coverage, increase premiums or lead to the discontinuation of benefits, result in my family paying for other services required for my child outside of school that would otherwise be covered by the Medicaid program or otherwise diminish my family’s insured benefits under the Medicaid program and that I will not incur an out-of-pocket expense such as payment of a deductible or co-pay amount.
I give my consent voluntarily and understand that I may withdraw my consent at any time. I also understand that my child’s entitlement to a free appropriate public education (FAPE) is in no way dependent on my granting consent and that, regardless of my decision to provide this consent; all the required services on my child’s IEP will be provided to my child at no cost to me.
Parent/Guardian Signature: ______Date: ______
PS 6001 S Parental Consent – English - Spanish May 2010
CHILD EMERGENCY INFORMATION
Please be sure to maintain a record of the following information for each child you provide services to, through Kidz Therapy Services. This information should be kept with you while you are providing services, in case of emergency and a copy returned to the Kidz Therapy Preschool Coordinator.
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: ______
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.
Emergency Contact (other than parent or guardian) Name: ______
Phone: ______Email: ______
Pediatrician Name/Phone: ______
ALLERGY PLAN FORM
To be filled out by Parent and Provider:
Child’s Name: ______DOB: ______
Known Allergy(ies): ______
______
Child’s typical reaction to exposure to allergen: ______
Indications that child is having an allergic reaction: ______
______
In case of emergency, provider will:
1. ______
2. ______
3. ______
4. ______
Name of Person(s) to be contacted: ______
Phone #: ______
______
Signature of Parent Signature of provider
Date: ______Date: ______
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______
Nassau County Department of Health
Preschool Special Education Program
PARENT/GUARDIAN CONSENT FOR ALTERNATE VERIFICATION SIGNATURE
I, ______, parent/guardian of ______give (Parent/Guardian’s Name Printed)
permission for:
Please all who will be able to sign – Day Care Staff, Teacher, Caregiver, etc. (must be over18)
1) ______Title: ______
2) ______Title: ______
3) ______Title: ______
______
(Parent/ Guardian Signature) (Date of Signature)
I, ______hereby withdraw the above permission as of
(Print name of Parent/Guardian)
______.
(Date of Withdrawal)
______
(Signature of Parent/Guardian) (Date)
NASSAU COUNTY
DEPARTMENT OF HEALTH
OFFICE OF CHILDREN WITH SPECIAL NEEDS
Preschool Special Education Program
60 Charles Lindbergh Blvd. Suite 100, Uniondale, New York 11553-3683
PRESCRIPTION FOR PRESCHOOL BASED RELATED SERVICES
Student’s Name: DOB: ______
Agency/School ______District: ______
The child named above is recommended for the following service(s). Services when provided will be in accordance with the Individualized Education Program designed by the Committee.
Period of ServiceSchool year 7/1/12 - 6/30/13
Diagnosis (ICD9 code) REQUIRED
Use an ICD9 code for each service selected
Service/Therapy(Please check any that apply)
OT ICD9 Code ______
PT ICD9 Code ______
Speech ICD9 Code ______
Psy Co* ICD9 Code ______
NU** ICD9 Code ______
*Psy Co = Psychological counseling services