In the event that my child becomes ill or injured while in therapy and guardians/emergency contacts are unable to be reached, I authorize the provision of emergency medical services to my preferred hospital. I give consent for the administration of any treatment deemed necessary by the treating physician. I understand that I will be liable for any costs associated under this consent to treatment.
PRE-NATAL & BIRTH HISTORY
Please elaborate if any of the following are checked
Please check all that apply
- Please read and initial each item:
I give consent for my child to receive the necessary evaluation and/or treatment by Chatterbox Pediatric Therapy.
Permission is given to Chatterbox Pediatric Therapy to release and/or request information when necessary for the records of the above-named individual.
I give consent to leave messages on my voicemail or reminder text messages at preferred number.
In an aid to enhance the quality of care, Chatterbox Pediatric Therapy may use an electronic surveillance system to record visual occurrences on the facility’s internal and external grounds, the only exception being private areas of restrooms. I acknowledgement that I am aware that Chatterbox Pediatric Therapy may use an electronic surveillance system and I understand that video surveillance may be used for training, saftey, and investigative purposes.
I acknowledge that Chatterbox can contact me through email for appointment, financial, and treatment updates. I understand the risks that are associated with using this form of communication, including but not limited to information regarding your child’s treatment may be accessible to other parties on the web. Chatterbox will use reasonable means to protect the information sent and received by email and will treat such email messages with the same degree of confidentiality as medical records. I understand that Chatterbox cannot guarantee the security and confidentiality of email communications and I still request to use this form of communication knowing risk factors. I may withdraw this consent at any time by written communication with the office manager. I understand that by completing this information I will be enrolled in the patient portal through Fusion Web Clinic.
- Effective July 2021 Chatterbox Pediatric Therapy will require every family with patient responsibility (private pay, co-pay/deductible amounts) to have a credit card on file. Co-payments and deductible plan pre-pays amounts will be run each Friday for that week’s appointments. Chatterbox requires that all patient balances remain below $300.
Please list the credit card information below that you would like on file for your child. You may also verbally provide this to the office when you check in for your evaluation. You may change your method of payment any time.
Chatterbox Pediatric Therapy will make every effort to work with our clients regarding obligations for services whether payment may be through insurance, private pay, co-payment or other agreements.
We are thankful that you have entrusted your child’s care to us. We hope that you will find your experience with
Chatterbox Pediatric Therapy to be a fun and positive one.
It is very important that your child attends each session in order to make consistent progress.
attendance to therapy sessions allows routine practice of skills targeted in therapy as well as facilitates faster progress
towards their therapy goals. When children do not have consistent attendance, their progress slows, and they are more
likely to regress during these periods of time when they are not receiving services.
In following the policy below, you are helping to ensure your child is regularly attending therapy to meet their goals. This
policy also allows us ample time to offer any open times to children waiting for services.
All correspondence regarding cancellations and rescheduling of therapy appointments must go through the front
office. Families may notify clinician as well as a courtesy but are responsible for contacting the office.
Please arrive on time for your scheduled appointment to receive your full treatment time. If you are more than 10
minutes late, your appointment will need to be rescheduled.
Parents must complete the text check in and screening process prior to being seen for any appointments. Parents
are not allowed to check in prior to arriving at the facility.
A minimum of 24 hours' notice is required for non-emergencies.
Families are expected to make every attempt to reschedule any non-illness related missed appointments in order
to remain on the reoccurring schedule.
If an emergency occurs after our normal business office hours, please leave a message on the answering service,
enabling us to follow up to reschedule your appointment and ample time to notify the treating therapist(s).
Please do not bring your children to therapy when they are ill. Children must be free of fever (without use of
fever reducing medication), nausea or vomiting for 24 hours prior to returning to therapy.
Patients with attendance below 80% of scheduled appointments will result in being removed from reoccurring
appointments. This is the equivalent of missing more than 2/10 appointments for 2x a week or more than 1/5 1x a
Two consecutive No Call-No Show appointments will result in immediate removal from the reoccurring schedule.
Repeated failure to comply with this Attendance Policy will result in your child losing their regularly scheduled
therapy times and moved to our flex scheduling option. This will require you to call for an open appointment on
each week/day you would like to receive therapy. We will do everything possible to accommodate you as space
on the schedule permits.
In the event that my child receives more than one therapy service (speech, occupational, physical), I understand that each one follows an individualized plan of care specific to my child's needs. It is important that they attend every scheduled appointment to address all areas of development needed to help my child improve. In the event that a clinician is out, resulting in one of the appointments to be cancelled, I understand that the office will do their best to reschedule with another clinician to help provide continuity of care. Should I decline to reschedule and/or cancel my child's other appointments in such a situation, I understand that the attendance policy will be applied, and a no show/late cancellation fee may be assessed for each scheduled appointment that is not kept.
No-Show/Late Cancellation Fees may be charged for repeat offenses of the following situations:
Failure to show for a scheduled appointment without proper notification of absence.
Failure to notify office of cancelled appointments within 24 hours of the scheduled appointment when applicable.
Chronic arrival to appointments beyond the 10-minute mark, resulting in cancellation of therapy.
A $65 No-Show/$40 Late Cancellation fee will be applied for failure to follow our attendance policy. For patients
with multiple appointments in one day, the fee will not exceed $100 per day.
Families are allowed these fees to be waived for one date of service per quarter.
These fees may be waived in the circumstance that a no-show or late cancelled appointment is rescheduled and
kept within one week of the missed appointment. Full payment of any assessed cancellation fees must be paid in
full before your child may return to their regularly scheduled appointments and moved to flex scheduling. unpaid
no show or late cancellation fees over 90 days may result in turning the account over to a third-party collection
We appreciate your cooperation and compliance with our attendance policy. We look forward to working together to help
your child reach his/her full potential.
By signing, I acknowledge that the above has been reviewed with me and I have full understanding of the attendance
- Many insurances require IEPs and IFSPs for authorizations and payment for therapy services. Therefore, failure to allow Chatterbox to obtain these records may prevent your child from receiving services at Chatterbox Pediatric Therapy.
Release of Medical Records
- I hereby request the release of records from the following entity (Please list child's school if they have an IEP)
- To be released to:
- Chatterbox Pediatric Therapy, LLC
110 Pipemakers Circle, Suite 115
Pooler, GA 31322
Fax Number: 912-988-1537
Attention: Medical Records
- Chatterbox Pediatric Therapy, LLC
2453 G US Highway 17 South
Richmond Hill, GA 31324
Fax Number: 912-445-5653
Attention: Medical Records