Payment Policy

I authorize Monica Fouquet-Tyler, SLP and/or Move2Play Pediatric Physical Therapy to bill my insurance company directly for the covered portion of charges, and I authorize payment of medical benefits directly to Monica Fouquet-Tyler, SLP and/or Move2Play Pediatric Physical Therapy.

I authorize Monica Fouquet-Tyler, SLP and/or Move2Play Pediatric Physical Therapy to release medical or other information necessary to process this claim.

I understand that the verified estimation of benefits is provided as a courtesy, and does not guarantee coverage. I realize that I am ultimately responsible to know my level of coverage.

Monica Fouquet-Tyler, SLP and/or Move2Play Pediatric Physical Therapy will submit claims to my health insurance company. I am responsible for payment of my deductible, co-insurance or co-payment, and any charges not reimbursed by my insurance carrier.

It is my responsibility to inform Monica Fouquet-Tyler, SLP and/or Move2Play Pediatric Physical Therapy of any and all changes of insurance coverage during the course of treatment. Failure to do so may result in denial of coverage by my insurance company. If my insurance changes, Monica Fouquet-Tyler, SLP and/or Move2Play Pediatric Physical Therapy will bill my new insurance company, but there is no guarantee they will cover the services.

Monica Fouquet-Tyler, SLP and/or Move2Play Pediatric Physical Therapy uses a billing company to process claims and payments. The billing company is of our choice and their employees will have access to protected patient information. This is for the purposes of providing insurance companies with needed information to process claims. Your initials indicate your permission to share protected patient information in order to process payments on your child’s behalf.

I hereby consent to such treatment procedures and patient care which, in the judgment of my therapist and/or physician, may be considered necessary or advisable while a patient of Monica Fouquet-Tyler, SLP and/or Move2Play Pediatric Physical Therapy. Physical, occupational, and speech therapy is a patient care service that is provided in order to manage a wide variety of conditions. Services are provided to individuals of all ages regardless of gender, color, ethnicity, creed, national origin, or disability. The purpose of physical, occupational, and speech therapy is to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis and intervention by use of rehabilitative procedures, mobilization, massage, exercises, and physical agents to aid the patient in achieving their maximum potential within their capabilities and to accelerate convalescence and reduce the length of functional recovery. All procedures will be thoroughly explained to you before you are asked to perform them. Response to therapy intervention varies from person to person; hence, it is not possible to accurately predict your response to a specific modality, procedure, or exercise protocol. Monica Fouquet-Tyler, SLP and/or Move2Play Pediatric Physical Therapy does not guarantee what your reaction will be to a specific treatment, nor does it guarantee that the treatment will help resolve the condition that you are seeking treatment for. Furthermore, there is a possibility that the physical, occupational, and speech therapy treatment may result in aggravation of existing symptoms and may cause pain or injury. It is your right to decline any part of your treatment at any time before or during treatment, should you feel any discomfort or pain or have other unresolved concerns. It is your right to ask your therapist about the treatment they have planned based on your individual history, physical, occupational, and speech therapy diagnosis, symptoms, and examination results. Consequently, it is your right to discuss the potential risks and benefits involved in your treatment. I have read this consent form and understand the risks involved in physical, occupational, and speech therapy and agree to fully cooperate, participate in all physical, occupational, and speech therapy procedures, and comply with the established plan of care. I authorize the release of my medical information to appropriate third parties.

I hereby release, discharge and acquit Monica Fouquet-Tyler, SLP and/or Move2Play Pediatric Physical Therapy, it’s agents, representatives, affiliates, employees or assigns of and from any and all liability, claim, demand, damage, cause of action, or loss of any kind arising out of or resulting from my refusal to accept, receive or allow emergency and or medical services, including but not limited to ambulance service, Emergency Medical Technician, physician or urgent care services.

As of July 1, 2013 according to the State of Kansas Physical therapy Practice Act, Statue 65-2921 states that patients may refer themselves to a physical therapist without a referral from their physician or other health care provider. As stated in this statute it is our responsibility to inform you that at the conclusion of an initial evaluation, we will not be providing you with a medical diagnosis but rather a physical therapy diagnosis and appropriate physical therapy goals to work towards in future physical therapy visits. In the event that you do not make measurable progress towards the physical therapy goals set by you and your physical therapists within 10 visits or 15 business days after your second visit with your physical therapist we are then required by law to receive a referral from an appropriate “licensed health care practitioner” to continue your physical therapy plan of care. A “licensed health care practitioner” means a person licensed to practice medicine and surgery, a licensed podiatrist, a licensed physician assistant or a licensed advanced practice registered nurse working pursuant to the order or direction of a person licensed to practice medicine and surgery, a licensed chiropractor, a licensed dentist or licensed optometrist in appropriate related cases.

I hereby acknowledge that I have received a copy of this Clinic’s Notice of Privacy Practices.

When you schedule an appointment with Move2Play Pediatric Therapy, that time is reserved exclusively for you. We understand that unexpected situations may arise; however, we ask that you provide at least 24 hours' notice if you need to cancel or reschedule an appointment. Late Cancellation and No-Show Fees will be assessed as follows: * Appointments canceled with less than 24 hours' notice will incur a $30 administrative fee for regular treatment sessions. * Evaluation appointments canceled with less than 24 hours' notice will incur a $60 administrative fee. * These fees are not billable to insurance and will be charged directly to the credit card on file. To help avoid missed appointments, please ensure that we have your current phone number and email address so that appointment reminders can be sent to you. Regular attendance is essential to achieving therapy goals and maintaining compliance with your prescribed plan of care. If a patient accumulates three (3) missed appointments within a calendar quarter for reasons other than illness or emergency circumstances, it may be determined that the patient is not adhering to the recommended treatment plan. In such cases: * Therapy services may be discontinued. * The referring physician and/or primary care provider may be notified. * Upon request, families will be provided with information for up to three alternative therapy providers should they wish to pursue services elsewhere. We appreciate your cooperation and commitment to your child's therapy program.

I have read and agree to abide by the above policies and am aware of the privacy policy. I agree to the Payment Policy/Assignment of Benefits/Authorization to Release Medical Information.