Client Agreement at Sensory KIDS
Welcome to Sensory KIDS! We are looking forward to working with you! Please review the following policies below to better understand our therapy process. There will be a form at the end of the page to indicate and sign your agreement. The typing of your full name and date is representation of your signature and agreement to abide by said policies. Any questions regarding the information included in this agreement can be directed to our front office at 503-575-9402 or by direct email to email@example.com. Thank you!
1. Payments including co-payment, private pay dues, and other out-of-pocket expenses are collected at the time of service. We accept payment by cash, check, VISA, MasterCard, American Express, and Discover Card. Families are financially responsible for all charges whether or not services are covered and paid by insurance.
2. Insurance is pre-verified. If Sensory KIDS is contracted with your insurance provider, we will bill your provider on your behalf. IN NETWORK deductible and co-insurance amounts will be billed to you after claims have processed through insurance. Our billing team, MBA Medical Billing, sends out statements on the first of each month. Please be aware that some services provided may be non-covered services and/or not considered reasonable and necessary under Medicaid, as well as other medical insurance companies. If for any reason a portion of a bill or service is not paid by insurance as expected, you are responsible for prompt payment of the remaining charges.
If Sensory KIDS is not contracted with your insurance provider, payment will be collected at the time of service until the individual or family OUT OF NETWORK deductible has been reached (whichever comes first). Sensory KIDS, LLC and MBA Medical Billing will track all payments toward your out of network deductible limit. If you are due a refund at any point, as a result of co-insurance kicking in or an abrupt change in coverage, you will be issued one promptly. Once the out of network deductible has been met, MBA will begin to bill you on the first of each month for co-insurance charges. The following charges will be applied to your out of network deductible until it has been met:
$165 per OT session and/or $165 per parent education meeting
3. Evaluations will be billed to insurance. It is your sole responsibility to financially cover payment for the evaluation service if an evaluation has already been rendered at another facility and submitted to insurance for payment within a given period of time. Insurance will only cover one evaluation per set number of days.
4. You can set up a payment plan at any point in therapy, if this is more of a financially feasible option.
5. We request prompt payment on all statements sent by MBA Medical Billing. Balances after insurance reimbursement are due within 30 days of the statement date, unless other payment arrangements have been made with Sensory KIDS.
6. Outstanding Bills: Sensory KIDS reserves the right to request payment for any outstanding balances. All outstanding balances greater than 45 days past due will result in treatment termination. In order for treatment to be reinstated, the due balance must be paid in full or a payment plan agreement must be signed. All outstanding balances 120 days past due will be sent to a collection agency.
FOR MEDICAID MEMBERS ONLY: Medicaid members cannot be balance billed on unpaid claims, however Sensory KIDS reserves the right to terminate treatment due to any issues related to unpaid claims. Medicaid members can be billed out-of-pocket expenses related to no-show or late cancellation fees, per this signed client agreement. All Medicaid members are required to maintain active Medicaid status throughout therapy.
7. Personal checks that do not clear due to insufficient funds shall be resubmitted to Sensory KIDS, along with payment for any charges associated with the bounced check.
8. Private Pay clients may request a payment plan agreement at any point during therapy. Payment plans for Private Pay clients are maintained by Sensory KIDS and not MBA Medical Billing. Private pay dues are collected at the time of service.
Sensory KIDS is in-network with the following insurance companies: Aetna, Moda Health, TriCare, Cigna, OHP/Care Oregon, Health Share OHSU and Regence BCBS. Sensory KIDS is able to bill as an out-of-network provider to United Health Care, Providence, and Pacific Source. If you have an insurance plan that we do not bill for, Sensory KIDS will provide a superbill at your request to submit to insurance on your own.
As a courtesy to our clients, Sensory KIDS provides a verification of insurance benefits and eligibility before services are rendered. This information is not a guarantee of payment and all services are subject to the terms and agreement of your insurance plan. Your insurance is a contract between you, your employer, and your insurance company. As such, Sensory KIDS is not a part of this contract and bills insurance as a courtesy. It is your responsibility to clarify the terms and conditions of your insurance plan. Accurate information on covered services is only available once a claim has been made.
- Should your insurance coverage change, it is your responsibility to notify our office within 30 days of the effective date. A new copy of insurance cards must be provided. Following the 30 days, if no new insurance information is received, Sensory KIDS will no longer bill on your behalf, and all future claims and/or charges will be patient responsibility.
- Sensory KIDS will obtain any prior authorizations required by your insurance plan. If a PCP referral is required, it is your responsibility to obtain one before services can be rendered. All OHP plans MUST have a PCP referral on file for insurance requirements before treatment can begin.
- Sensory KIDS will assist with tracking visits; however, it is your responsibility to track used visits in accordance with the number of visits allowed and/or approved by your insurance plan. The number of visits approved by your insurance plan is NOT related to the recommendation of our therapists. If therapy exceeds the number of allowable and/or authorized visits, you will be responsible for any out-of-pocket expenses. It is important to understand hard limits to the number of visits allowed by your insurance plan. Sensory KIDS may request additional visits on your behalf based upon the recommendations of the therapist and the limitations of your plan, but we cannot guarantee that additional visits will be approved.
- If at any point in your therapy, insurance no longer covers a service due to a lack of medical necessity, our office will appeal on your behalf at your request (when applicable). However, it is your responsibility to pay for any uncovered charges. We do not accept responsibility for paying or negotiating any settlements on unpaid claims, especially in the case of an appeal denial.
Sensory KIDS understands that financial problems may unexpectedly arise and affect payment on your account. If this is the case, we urge clients to contact Sensory KIDS or MBA Medical.
Sensory KIDS is committed to providing exceptional care and support to the children and families we serve. Our therapists are dedicated to using best-practice and evidence-based methods to help your child reach goals and feel successful. That means putting time and effort into planning each individual session. Please respect our dedication by committing to scheduled appointment times and the agreed-upon treatment plan. In order to ensure the most effective use of your therapy time, we ask that you carefully review and initial the statements below.
PLEASE NOTE: Insurance companies DO NOT REIMBURSE for any of the fees listed in this policy.
*All fees in this Cancellation Policy are parent/guardian responsibility*
- General Policy Statement: Any changes to your ongoing treatment schedule should be requested to our front staff, not the therapist. Sensory KIDS cannot guarantee that your schedule request will be met, however, we will do our best to accommodate. We understand that abrupt endings to therapy may occur in the face of difficult financial situations or life events, but we do ask that you provide at least a 48-hour notice prior to ending, so the therapist may prepare the next session for a transition out of therapy.
- Appointment Reminders: Our scheduling system, Clinic Source, will send you a reminder email 48 hours before your appointment. You may choose to cancel or confirm your session via this reminder email. However, Sensory KIDS asks that you follow-up by phone or email if your session needs to be cancelled.
- Inclement Weather Policy: The clinic is open except in cases of severe conditions requiring businesses to close. It is your responsibility to call the clinic to determine whether changes in the scheduled time of treatment are needed, and if the opening of the clinic is delayed. Clients may cancel treatment if they do not wish to travel because of inclement weather, however, if the clinic is open, a $50 late cancellation fee will be charged for missed appointments that were not given at least 24-hours’notice.
Sensory KIDS is able to hold therapy spots for up to two weeks. If you are pulled off the schedule for any reason, we will do our best to fit you back in as soon as possible.
Scheduling and Consultation Policy
General Scheduling Statements: Treatment sessions run 50 minutes long, but are scheduled for 1 hour. The last 10 minutes of your session is utilized for transitions out of therapy, parent check-ins, and therapist notes. Treatment sessions are scheduled back-to-back, and as a result, treatment time cannot be extended.
Following the initial evaluation, Sensory KIDS recommends a round of 30 treatment sessions or a short burst in therapy, whichever is most applicable. Treatment sessions will be scheduled based upon your availability and the availability of your therapist. Parent education meetings can be scheduled for teen clients or clients that require guardian/parent care or supervision. Parent education meetings can be used to review evaluation results, progress, and collaboration on goals/treatment plan.
*All clients who plan to return to Sensory KIDS after taking a break will be placed on the therapist’s priority list with a projected return date. Our office will reach out to you close to this projected return date in an effort to establish a new treatment schedule.
Communication: For our younger adult clients, we offer families the opportunity to schedule a 15-minute complimentary phone consult when a short consultation is sufficient. Additionally, parents/guardians may request an adult-only parent meeting with the therapist at any time.
Legal Consultation: Any fees associated with legal counsel or court appearances will be billed to your lawyer, or you directly, at the out-of-pocket rate of $165/hour. This fee is NOT COVERED by insurance. All requests for legal counsel should be directed to Sensory KIDS front staff for scheduling purposes. Therapists are not obligated to discuss legal matters over email.
Professional Consultation: Therapists at Sensory KIDS are willing to work closely with any professionals related to your care. Information can be shared once a Release of Information Form has been filled out appropriately and returned to our front staff. Consultations with related medical professionals will be billed to insurance when applicable. Private pay clients will be billed for professional consultations in 15-minute increments at the hourly therapy rate. Therapists are not obligated to discuss your therapy with related medical professionals over email.
Emails: Email communication should be used for quick updates regarding your therapy. Email communication taking over 10 minutes will be billed in 15-minute increments at the hourly therapy rate to you. This fee is NOT COVERED by insurance.
At Sensory KIDS, we handle most of our communication to clients through our main email account: firstname.lastname@example.org. This email is HIPAA protected, making it safe to discuss your therapy and to send any documentation related to your therapy. The following will be handled by email, unless otherwise requested by phone:
- Initial Intake
- Scheduling the initial assessment, any parent meetings, as well as treatment sessions
- Appointment reminders through ClinicSource
- Notices of therapist absences
- Notices of office closures
- Cancellation and rescheduling of treatment sessions
- Schedule requests and/or changes
- Payment questions and receipt sending
- Insurance related inquiries or issues
- Sensory KIDS Monthly Support Group emails
- End of treatment surveys
- Recruitment for research projects
Sensory KIDS, provides support for all clients and families without regard to race, color, religion, sex, disability, gender identity, sexual orientation, or age. We hope to provide a place of comfort and safety to our families, in addition to an atmosphere that is positive, fun, and inviting. So Sensory KIDS can make a comfortable and safe space for all, we ask that clients respect the following:
- Children are prohibited from climbing walls and/or jumping from any surfaces or office furniture. Office toys, books, or crafts should be handled with care under the supervision of a parent/guardian.
- Please clean up after your children in the waiting room. We ask that all books and toys are put back where they were found. Trash and recycle can be found in the waiting room under the front desk.
- All children should be accompanied by a parent or guardian when going to the restroom. Any families with children who require diapers or pull-ups should bring a diaper bag to therapy and be prepared to change your child if necessary.
- Children are NOT allowed in the treatment area unless accompanied by the therapist.
- Before entering treatment areas, we ask that shoes be removed and placed by the front door. Any coats/jackets can be placed on the available wall hooks.
- No outside food should be taken beyond the waiting room, with the exception of food therapy sessions. Please clean up any food messes that occur, and notify the front staff immediately if further assistance with cleaning is required.
- Please refrain from cell phone conversations in the waiting area. Please keep tablet use to a minimum, ensuring the volume is on silent. Necessary phone conversations can be carried out in an available observation room or outside the clinic.
- In compliance with HIPAA, front staff and therapists are unable to discuss any other families/clients who may be receiving therapy at the clinic. Please be mindful of the content discussed with your family members, as well as the therapist.
Acknowledgement of Risk: There is some risk inherent in the use of therapy equipment at Sensory KIDS. By signing below, you agree to indemnify and hold Sensory KIDS, LLC harmless from any and all losses and claims for injuries or damages that may occur to you, your family, and your belongings from the use of our therapeutic equipment.
It is the policy of Sensory KIDS to discharge clients when they have met the following criteria:
- Sufficient Progress – When you have demonstrated sufficient progress, the therapist will review your progress and recommend a break. A hard end date will be established mid-way through treatment for clients whose therapist has recommended a break.
- Financial Responsibility – If a client is not accepting financial responsibility as outlined in our financial policy, the client’s therapy may be terminated.
- Attendance – If three consecutive sessions are cancelled or marked as no-shows, the client’s therapy will be immediately terminated.
- Family Request – Discharge of a client can be requested by the client or client’s family. We ask that clients provide 48-hours’ notice if they know they will be ending therapy.
- Agency Discretion – Sensory KIDS reserves the right to discharge any client at any time for any reason
Sensory KIDS is a teaching facility that values learning and education. Master and doctorate level students studying occupational therapy complete internships at our facility, and therefore, will frequently observe and take part in therapy sessions, with the therapist giving notice. Additionally, volunteers are frequently onsite to support therapists and administrative staff, and may observe sessions as deemed appropriate by the therapist. Both intern students and volunteers adhere to our clinic policies and federal privacy guidelines.
Photograph and Video Release
In compliance with federal and state regulations your permission is sought to allow yourself to appear in photographs and/or videos recorded in our clinic. Clients involved in recording will not be identified in any manner.
Client Agreement Fillable Form
After carefully reviewing the above policies and procedures, please click the button below to take you to the online Client Agreement form.