Client Agreement Fillable Form

Choosing “Yes” from the options below is you indicating your agreement to abide by the policies and procedures outlined in the Client Agreement. Typing your full name and date in the spaced indicated will serve as your electronic signature.

Client Name*

First

Last

Parent/Guardian Name (if applicable):

First

Last

1/6

I give Sensory KIDS, LLC and MBA Medical Billing permission to bill my insurance provider directly, if applicable.*

Yes

I understand that copayments, private pay fees, out-of-pocket expenses, and fees related to my out of network deductible are due at the time of service.*

Yes

I understand that I can request a payment plan with Sensory KIDS and MBA Medical Billing at any point while receiving services.*

Yes

I understand that in network deductible and co-insurance amounts will be billed to me on the first of each month by MBA Medical Billing. I understand that Sensory KIDS has the right to request payment for outstanding balances. I understand that if I have an outstanding balance greater than 45 days, my treatment will be terminated until payment has been made. I understand that outstanding balances 120 days past due will be sent to a collection agency.*

Yes

I have confirmed with my insurance provider the information provided to me in the verification document originally sent by Sensory KIDS, including my plan’s coverage limitations, co-pays, and co-insurance. If I am paying privately, or for any out-of-pocket expenses, Sensory KIDS has reviewed with me the details of their service costs and I understand my financial responsibility in making payments at the time of service.*

Yes

I understand that if my insurance is OHP, I must obtain a PCP referral for Sensory KIDS, LLC before treatment begins. I understand that a PCP referral is required by OHP for insurance and authorization purposes.*

Yes

I understand that Sensory KIDS, LLC only assists in the tracking of visits and it is my responsibility to track my visits. I understand that if for any reason therapy exceeds the number of allowable and/or authorized visits, I will be responsible for any out-of-pocket expenses.*

Yes

I have read the above information and understand that, as a client, parent or guardian, I am ultimately responsible for payment of all services provided by Sensory KIDS, LLC. In the event that my insurance company refuses payment for services for any reason, or if any other source of payment falls through, I will be responsible for all past, current, and future service charges.*

Yes

For your convenience, you have the option of placing a card on file for automatic payments related to copays, deductible, private pay dues, or co-insurance charges. Please mark whether you would like a card to be placed on file, or not. If you would like to keep a card on file, please provide the appropriate information below. Please note, that if you does not choose to place a card on file, any payments due at the time of service must be made in person before the treatment session begins.*

Yes

CARD INFORMATION

Name of Card Holder Number on Card Expiration CSV

BILLING ADDRESS

Street Address City State Zip Code

If providing a card on file, I understand Sensory KIDS, LLC will charge my card automatically for any co-payments and/or private pay fees related to my deductible or out-of-pocket responsibility at the time of service.*

Yes

Not Applicable

If providing a card on file, I would like Sensory KIDS, LLC to charge my card automatically on the first of each month regarding any due balances on my account.*

Yes

Not Applicable

If providing a card on file, I would like Sensory KIDS, LLC to send me a copy of my purchasing receipt via email for each transaction run on my card.*

Yes

Not Applicable

If a card was not provided, I understand that all private pay and/or out of pocket expenses must be paid in-person, at the time of service.*

Yes

Not Applicable

If a card was not provided, I understand that if my out of network deductible has not been met, I will be responsible for the following charges at the time of service: $165 per OT session and $165 per Parent Meeting*

Yes

Not Applicable

I hereby understand the financial policy of Sensory KIDS, LLC and agree to abide by it.*

Full Name

Date

2/6

I understand that it is my responsibility to communicate any schedule changes or requests to the front desk, not my therapist.*

Yes

Clients who arrive later than 15 minutes into their appointment time will be charged a $50 late cancellation fee, and will result in the appointment being cancelled for that day. Appointments cannot be extended, as they are scheduled back-to-back. Therapy is not effective if not given the full amount of time. We ask that you respect the therapist’s time, as well as your own, and allow youself plenty of time to make it to your appointment.*

Yes

If an appointment is cancelled with less than 24-hours’ notice, except in the case of illness, the appointment will count as a late cancellation and you will be charged a $50 late cancellation fee. I understand that 3 cancelled appointments in a row will result in the termination of my scheduled treatment times. Exceptions to this are previously planned absences made with our front office at least 1 week prior to the cancelled dates.*

Yes

Treatment sessions are 50 minutes long, but are scheduled for 1 hour. Parent/Guardians (if required) are expected to show at the 50-minute mark to assist with the transition out of therapy and check in with the therapist. If a required parent/guardian does not show at the 50-minute mark, a $25 late pick-up fee will be charged to my account for every 10 minutes over my therapy time.*

Yes

I understand that if I fail to show up to my appointment with no notice, I will be charged an $88 no-show fee. I understand that 3 no-shows will result in the termination of my scheduled treatment times.*

Yes

If you are sick with a temperature over 100 degrees, a cough, or has vomited in the last 24 hours, please immediately call our office to cancel your appointment. Cancellations due to illness will not be charged a cancellation fee.*

Yes

Feeding sessions require a significant amount of money and time for planning and preparations. I understand that if I am doing feeding therapy, I will be charged a one-time fee of $50 that will cover food costs for all of my feeding sessions. Additionally, if I need to cancel my feeding session, I understand that I need to give 48-hours’ notice, except in the case of illness.*

Yes

I give Sensory KIDS, LLC permission to send reminder emails via their Clinic Source scheduling system to the email address I originally provided.*

Yes

I have read and understand the Inclement Weather Policy.*

Yes

I hereby understand the cancellation policy of Sensory KIDS, LLC and agree to abide by it.*

Full Name

Date

3/6

I understand that treatment sessions run 50 minutes long, and that any payments or scheduling needs should be taken care of at the beginning of my session. *

Yes

I understand that longer conversations about my therapy will be saved for designated parent education meetings or email. I understand that I may request a meeting or phone consultation at any point in my therapy, and will be responsible for all service charges related to my request.*

Yes

I understand that parent education meetings are adult-only. I understand that children are not allowed in parent education sessions and cannot be left unsupervised during these sessions.*

Yes

I understand that I will receive a hard end date mid-way through treatment based upon the recommendation of the therapist (when applicable). I understand that this hard end date is established for scheduling purposes and cannot be adjusted in the case of cancellations, therapist absences, and office closures.*

Yes

I understand that cell phones are disruptive and are not to be used in the clinic during sessions, especially in the waiting area. If observation rooms are open, clients may take any necessary calls in these rooms with the door closed upon notifying front staff. All other calls should be taken outside the clinic.*

Yes

I understand that any fees associated with legal consultation will be billed to my lawyer or directly to my family. I understand that all requests for legal consultation will be directed to the front staff.*

Yes

I understand that professional consultations require a signed Release of Information form, and that all requests should be made directly to the front staff. I understand that I will be responsible for any charges associated with my request.*

Yes

I understand that I will be responsible for any charges associated with lengthy email communication.*

Yes

I hereby understand the scheduling and consultation policy of Sensory KIDS, LLC and agree to abide by it.*

Full Name

Date

4/6

I understand that Sensory KIDS’ main communication is done through email.*

Yes

I give Sensory KIDS permission to email me for anything associated with my therapy.*

Yes

If there is something that I would like Sensory KIDS to directly contact me by phone for, it would be (put n/a if not applicable):

I hereby understand Sensory KIDS, LLC’s communication notice.*

Full Name

Date

I have read and understand the Discharge Policy. I understand the Sensory KIDS reserves the right to discharge any client at any time for any reason.*

Yes

I hereby understand and will adhere to the office etiquette and acknowledgement of risk as outlined by Sensory KIDS, LLC.*

Full Name

Date

I give permission for occupational therapy students to participate in my therapy session.*

Yes

I understand that my I may be photographed or videotaped for educational purposes. I understand that any such records or photographs will be reviewed by me prior to any release.*

Yes

I understand that volunteers may observe my session, as deemed appropriate by my therapist.*

Yes

I hereby understand and agree to the teaching and research activities outlined by Sensory KIDS, LLC.*

Full Name

Date

5/6

I give permission for Sensory KIDS to use my photo for their Medical Software System.*

Yes

I give permission for Sensory KIDS to use my photo(s) and video recordings for review by their therapists.*

Yes

I give permission for Sensory KIDS to use my photo(s) and video recordings for educational purposes.*

Yes

I give permission for Sensory KIDS to use my photo(s) and video recordings for marketing purposes.*

Yes

6/6

Client Agreement Fillable Form – Adult

Client Agreement Fillable Form

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Client Agreement Fillable Form

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