Thanks again for allowing us the opportunity to exceed your expectations.

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Neal Park
6 years ago
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1 Thank you for choosing Kids Kount Therapy for your outpatient therapy needs. Whether you are a current client or a new client to Kids Kount Therapy, this packet serves as a means of communication with you regarding our policies, insurance information, and general information. Please read the enclosed information and feel free to ask questions at any time. Thanks again for allowing us the opportunity to exceed your expectations. OUR MISSION: Kids Kount was founded with a purpose of providing children with special needs an opportunity to achieve their full potential while receiving individualized therapy services in a positive, caring environment. Although Kids Kount provides a wide range of speech, occupational, and physical therapy services, particular emphasis is placed on children diagnosed with autism spectrum disorders, auditory processing disorders, and sensory integration dysfunction. Kids Kount strives to be a support system for the children and families of Baldwin County with rehabilitation needs. In doing so, the therapists seek to implement treatment approaches and education which facilitate quality of life improvements for the clients and their families. GENERAL INFORMATION Office Fax Our staff is made up of licensed professionals who work together to bring you the highest quality of therapeutic care available. Our clinic is made up of physical therapists, physical therapy assistants, occupational therapists, occupational therapy assistants, speech language pathologists and an audiologist. We feel it very important to educate and serve as an education site for local colleges, specializing in graduation of the above disciplines. There may be times your child will be treated by a student/intern under the direction of a staff member. OFFICE HOURS: Our clinic hours are from 8:00 am to 5:00 pm Monday through Thursday. Our office personnel are available 8:00 am to 5:00 pm Monday through Thursday. We are closed on Fridays, Saturdays, and Sundays. We do provide appointment times, as we are able, during these times on a limited basis. We observe most major holidays. INCLEMENT WEATHER: During severe weather we may choose to close the office. You may call and if we are closed there will be a message giving closing and reopening information.

2 ATTENDANCE/CANCELLATIONS: Your appointment will be scheduled by our office staff and is dependent on current therapy caseload availability. Afternoon times are considered prime treatment times during the academic school year. A good attendance record is required to maintain your time slot with your therapist on a regular basis. It is required to attend 80% of your scheduled appointments or you will be at risk of losing a preferred time slot. In addition, there is a $40.00 fee charged to your account for failure to cancel your appointment with a minimum of 24 hour notice. A $75.00 No show fee will be charged for noncancellation of initial evaluations. **You must call the front desk at to cancel your appointment. We will let the therapist know. If you would like to contact the therapist directly, in addition to the front desk, that is fine. **The front desk must be notified to ensure proper documentation of your cancellation to avoid fees.** FOR PATIENTS TREATED IN SCHOOL SETTING It is the parent s responsibility to cancel the appointment with a 24 hour notice, if a child is sick, on a field trip, or otherwise unable to be present. Our therapists have to travel to treat your child at school and a $40.00 no show fee will be assessed for appointment not kept. Please call for any schedule changes or cancellations. If you must cancel for your child due to illness, within the 24 hour window time frame, you will be asked to reschedule at the time of cancellation. The make-up must be scheduled for a time slot that falls within two weeks of the original scheduled appointment. If a make-up is not scheduled at the time of cancellation, a $40 fee will be billed to your account and can be credited if you get the appointment rescheduled and attended within the two week time frame. **During the school year, due to the high demand of the after school appointment times (3:00 and 4:00), a written medical excuse may be required. **If your child is scheduled for 4 or more weekly, recurring appointments during summer months and 3 or more during the school year, make-ups will not be required. (The 24 hour notice is still mandated and any after school hour appointments fees still apply.) SICKNESS: Clients will not be allowed to attend therapy at Kids Kount Therapy if they have been sick and running fever in the last 24 hours. Your child must be fever free for 24 hours without the assistance of medications to decrease fever. With infections that are treated with antibiotics, at least 24 hours of antibiotics but be administered before your child is approved to come back to therapy. A written notice from a physician may be requested for medical excuse. ****Parent signature needed here to acknowledge understanding of above attendance/cancellation policy**** Signature: Date: rv 09/14

3 BILLING/INSURANCE: As a courtesy, we do submit insurance claims for our patients. We are providers for Blue Cross Blue Shield, All Kids, Aetna, Tricare Standard, United Health Care, and Humana. If you have insurance other than these you may pay for your visit in full at the time of service and then we will provide assistance to help you file your claim with your insurance company for reimbursement directly to you. It is important that your insurance information be correct and current and that you notify our office of any changes in your coverage. Updated information is requested yearly. If claims are denied due to inaccurate or untimely information you will be held liable for the charges incurred. Covered benefits vary between insurance plans. Some insurance plans require pre authorization for therapy services. Therefore make sure that you have written documentation or an authorization number prior to accepting treatment. It is your responsibility to understand the limitations and exclusions of your policy. Clients will be expected to pay co-payment and/or deductibles at the time of service. Furthermore, I agree that by signing this document that I will be responsible for non-covered services, deductibles, co-pays or co-insurance. Deductible or co-pay amount will be due at the time of each visit. We will charge the credit card on file for those services on the day of each visit. We require a credit/debit card on file for all patients. If a credit/debit card is not available, cash or check payment must be made for one full month in advance. If after the 10 th of the month, your account has a balance that has not been settled, therapy sessions will have to be discontinued until payment arrangements have been made. Therapy time slots will not be held for this reason, and you will be at risk of losing your preferred therapy time slot. If you do not receive a monthly statement, it is your responsibility to let the front office know, in writing, that you are requesting that statements be sent. An on demand statement can and will be printed at your request at the front desk. Your insurance company will send an explanation of benefits (EOB) to you to report each claim filed as well. This form will detail the portion you are responsible for, including deductible, co-insurance and non-covered services amounts. If you fail to make payments or contact us to make arrangements for a payment plan, a minimum 20% collection fee will be added to your balance and your account will be turned over to a collection agency. To avoid damage to your credit rating, please stay in contact with us and honor your obligation to pay for services. Parent Signature: rv 08/15

4 MEDICAL RECORDS RELEASE: Confidentiality of your medical records is our priority and will be kept in the strictest privacy. Kids Kount may share your records with your referring physician, insurance company, or to obtain payment. We require a minimum of seven days, after receiving your written permission, to release your records to another facility. There may be a nominal fee applied to such requests exceeding 5 pages. THERAPY EVALUATIONS/TREATMENT: All services at Kids Kount Therapy require a physician referral to begin the evaluation process in our facility. The evaluation process may take anywhere from 45 minutes to 1 1/2 hours depending on the individual needs of each child. It is possible that testing may require more than 1 visit to complete. We usually have results ready for review by parents within two weeks, if not earlier. Upon receiving a signed release form, we can provide a copy of the evaluation results to other professionals as requested. We also feel that it is extremely important to meet with parents/caregivers following the evaluation process to review results. We do ask that children NOT be present for this meeting to allow for ample opportunity for questions. There is a $30.00 charge for a 30 minute consult, or $60.00 for one hour. This is not billable to insurance and must be paid at the time of service. You may elect to have just the results of the evaluation and recommendation for treatment ed, but we feel that your child s needs will be better addressed if you agree to a consult with your therapist. All of your questions will be addressed at the time of the consult. If you are referred for multiple disciplines, all evaluations must be complete before this meeting will be scheduled. Standard therapy sessions (excluding ILS) are scheduled on the hour and are 50 minutes in length. The last 10 minutes are needed for parent education regarding how your child performed in therapy and to share goals and recommendations for home. Caregivers are expected to be waiting in the facility for their child at 15 minutes until the end of the session. (Ex. A client with a 2:00-3:00 pm appointment time - caregivers must be in facility to pick up child no later than 2:45 pm). Please be considerate of this policy so that all patients may receive prompt attention. Caregivers leaving the facility during therapy sessions are required to report a working cell phone number to staff in case of emergency. If you do not have a working cell phone contact number, please remain on site during treatment. In addition, Kids Kount is not liable for accidents or incidences that occur involving your child when they are not with their therapist. Parents must assume ALL responsibility for their child/children at all times until their therapist is present. No one is allowed into therapeutic treatment rooms unless accompanied by a therapist. This is a strict policy put in place for safety reasons. Please remain in the waiting area for your therapist. PARKING: Please reserve handicap parking spaces for our clients and staff that met the criteria for parking in this area. Please also use cautious speed in our parking lot as children are in and out frequently. FACEBOOK: Kids Kount Therapy Services does have a Facebook page for use as a parent support system. You are welcome to join our Facebook family and we will approve any client and non-client individuals in our community that offers a service that we feel our clients may benefit from. Kids Kount Therapy

5 Services cannot be responsible for posts occurring within the Facebook page and does not monitor posts daily. Kids Kount Therapy uses this page as an information/community service page of events that are important to us and as a means of communication for all our families. Contact information: Shannon Norris Owner/Administration Phone: kidskountmgmt@yahoo.com Andrea Pointer Owner/Administration Phone: apointerslp@yahoo.com Kellie Boudin Operations Manager Phone: kellie.kidskount@yahoo.com THERAPIST contact therapistfirstname.kidskount@yahoo.com Occupational Therapy Staff Cindy Dawkins Shannon Norris Latoya Thomas (COTA) Mia Manning Emilee Rucker Clark Physical Therapist Melanie Restivo Audiologist Leah G Barter Speech Therapy Staff Katie Jett Janika Davis Maura Coley Shelby Cotner Andrea Pointer Audrey Veren Ashley Gibson Karen Shoemaker Laurie Reiney Leah Barter SLP-A

6 Kids Kount Policy and Procedure Acknowledgement Signature Form Client Name: Date: Caregiver Name: Guarantor: Address: City,State, Zip I have received, read, and agree to abide by Kids Kount Policies I give permission for Kids Kount staff to communicate with me through any of the following methods: Preferred Home Phone Cell Phone By signing this form, I consent to evaluation and treatment of my child by Kids Kount therapists and that I will be responsible for non-covered services, deductibles, copays/coinsurance, and that I understand that my credit/debit card will be processed weekly for copays, deductibles, or non covered services. Kids Kount policy is that the custodial parent (the one who normally would bring child for services) will be the responsible party and she/he will be sent statements. It is the custodial parent s responsibility to pay the account and then to collect from the other parties in accordance with legal mandates. If coverage is through All Kids please ask for a copy of Kids Kount Policy agreement regarding All Kids patients or initial indicating that you have already been given and signed the policy. If you plan to leave the premises during your child s treatment you must give the front desk receptionist a working cell phone number. Print Name: Signature: Date: Guarantor signature if different than person completing this form: Guarantor Name:

7 Guarantor Signature: Date: rv8/15 Kids Kount Therapy Credit Card Authorization (**Please note that if this form is not completed, you will be expected to pay a full month in advance before starting therapy. If you complete this form, we will run your card at the time of each visit.**) Due to the recurring appointment nature of therapy, we require this credit card authorization to be kept on file. Your card will be processed weekly on each and every visit for your deductible, copay, or non covered service. You still have the option to pay at the time of each visit or make payment prior to your visit each week. *If for some reason you are not getting statements, it is up to you to let our front office know. You should also receive EOB information from your insurance provider that will give you the same information. Patient Name: Name on Credit Card: Type of card: Visa or Master Card Card Number: Expiration Date: CVC code: I,, give my permission to Kids Kount Therapy to charge copays, deductibles or non-covered services weekly to this credit card. Signature Date *Please note our cancellation policy requires 24 hour notice unless there is sickness or other unforeseen emergency. Please call the front desk at to notify us. You may contact your therapist IN ADDITION but YOU MUST CALL FRONT DESK. In the case of emergency or illness, call us as soon as possible. No show fee of $40 for therapy session and $75 for evaluation will be billed to your account.* **Please sign here that you understand cancellation policy. Print Name Signature rv 8/15

Holistic Speech & Language Phone: (206) Fax: (206)

Holistic Speech & Language Phone: (206) Fax: (206) Client Intake Form Demographic Information Last Name: First Name: of Birth: Sex: Diagnosis (if known): Parent/Guardian Name(s): Home Address: Parent #1 Phone: Parent #2 Phone: Parent #1 Email: Parent #2