Patient Registration FormPatient Registration FormYou may download the detailed Patient Registration Form here to fill out at home and bring to your appointment. Step 1 of 50%Today's Date* MM slash DD slash YYYY Patient's Last Name*Date of Birth* MM slash DD slash YYYY Patient's Type* Child AdultEmail Address* Street Address*City*ZIP Code*Phone*Insurance CompanyInsurance Policy NumberPremera and Regence Members include Alpha PrefixGroup NumberSubscriber NamePolicy & Procedures – Child Client“Client” refers to the child and his/her parents.In order to reduce confusion and misunderstanding between our clients and Rock Therapeutic Services, we have adopted the following policies. If you have any questions about the policies, please discuss them with the clinic director, Adrienne Rock, or the Office Manager, Storch. We are dedicated to providing the best possible care and service to your family and regard your complete understanding of your responsibilities as an essential element of the care and treatment of your child.FINANCIAL RESPONSIBILITYRock Therapeutic Services is currently a preferred provider in the Premera, Regence, Aetna, Cigna, First Choice, Molina, and Kaiser-PPO insurance networks. Please refer to your benefits handbook or contact your insurance company to determine whether or not speech-language therapy is a covered service.Rock Therapeutic Services may verify the client’s benefits as a courtesy. Quoted benefits are not a guarantee of benefits, the client is ultimately responsible for verifying their own insurance benefits.Rock Therapeutic Services will submit insurance claims to the insurance company on the client’s behalf.Not all of Rock Therapeutic Services are covered by insurance. Meetings, consultations, and absences that do not conform to our cancellation policy are not covered services and will not be billed to insurers.Insurance claims can take 2-4 weeks to process. Rock Therapeutic Services will send you a monthly invoice for all remaining Patient Liability as shown on the Insurance Explanation of Payment.Payment is expected within 30 days of the invoice date. After 30 days the account is subject to collections.Please note that co-payment and cash payer fees are due at the time of service.We currently accept cash, check, Visa, Mastercard, and American Express. Please make checks payable to Rock Therapeutic Services. There will be a $34.00 service fee for all returned checks.The client is ultimately responsible for all charges of rendered services. If the insurance company determines that the services are not a covered benefit the client will be billed as a Cash Payer.If the client fails to disclose that they have a secondary or tertiary insurance plan, whether commercial or medical plan, they are responsible for all charges of rendered services not covered bu the primary insurance.Provider One/ Apple Health Clients – Rock Therapeutic Services does not submit claims to provider one or Apple Health or one of their managed care plans (except molina ) By signing this form you agree to pay out of pocket for all services rendered.FEE SCHEDULECall office for more information.CANCELED/MISSED APPOINTMENTS POLICYNon-Emergency: 24 Hours Notice This includes anything that is not designated by “emergency “ (see below) such as pre-planned doctor appointments, family events, parties, sporting events, lack of baby sitter, etc. The session must be canceled with 24 hours notice or it will be subject to a $75 fee. If cancellations become excessive for non-emergency purposes, then the client may lose his/her weekly slot in the therapy schedule.Emergency: Cancel by 10am Emergency cancellations are due to client illness, illness of a family member, or other unforeseen circumstances. These sessions must be canceled by 10am on the day of therapy or it will be subject to a $75 fee. If your child does not go to school, you should call first thing in the morning to report the illness. If your child gets sick during the school day and is sent home please notify us immediately to avoid a fee. Please do not bring your child with a fever, strep, diarrhea, vomiting or any highly contagious illness. In general if they are too sick for school they are too sick for therapy.Inclement Weather: Cancel by 10am When a storm is expected, or the roads are dangerous the office usually closes. It is understood that some clients may live far away, and while the office may not be closed, you may choose to stay home with your child. In this case you must follow the procedure for EMERGENCY cancellations and call by 10am that day if you think you would prefer not to travel or you may be billed a $75 fee.ALLERGIES / DIET RESTRICTIONSWhen you register your child for therapy, you will fill out an Allergy/ Diet Restrictions form. This form is kept in the child’s file which is present during every therapy session. It is crucial for every child to have this form filled out even if your child has no allergies. If you have food preferences or diet restrictions please make sure this is noted on the form. If you have not filled out this form or need to make changes please do so as soon as possible.DROP OFF / PICK UP TIMESPrior to the session, clients and siblings should remain in the waiting room until greeted by a therapist. Please do not ask our therapists, administrative staff or receptionist to watch your child.During therapy, parents are welcome to observe, wait in waiting room, or run errands.Typically, the therapist will allocate 3-5 minutes at the end of the session time to briefly discuss the session with the client’s parents. If a parent would like more time to discuss their child’s progress, they should let the therapist know beforehand so it can be planned for accordingly and still allow for an on-time end to the session. Parents are encouraged to schedule a consultation meeting if they have a number of issues they would like to discuss.Parents and/or caretakers must be ready to pick up their children promptly 10 minutes prior to the therapy session ending time.If parents and/or caretakers are late picking up the client they may be charged $25 for the first 0-5 minutes, and an addition $5 per minute thereafter.OBSERVATIONS / REPORTSOther professionals, therapists, etc. are welcome to observe our therapy. We do ask for notice if someone other than the parent wants to observe.Siblings should not be left unattended while parents are observing therapy. Siblings also should not accompany parents during observations, as it may be distracting to our clients. If siblings are present it is preferable that they wait in the waiting room area during therapy with adult supervision.If you would like a formal report written about your child, please ask your child’s therapist via email or in writing. Please allow 2 weeks for this report to be completed. If you would like the report to be sent out to other professionals (school, outside therapists), please indicate that in your request.CONFIDENTIALITYRock Therapeutic Services will keep all personal, medical, and insurance information confidential. Client information will only be released upon receipt of a signed and dated Healthcare Information Release form. Consent for a release of information may be withdrawn by the client at anytime with a written notice signed by the client.A copy of all evaluation and progress reports will be given to clients, parents, or guardians. Additional copies may be distributed to those persons with authorization based on the Healthcare Information Release form on file.If a client has requested that their insurance company be billed for therapy services, information will be shared with the client’s insurance company as needed to submit claims for services provided, as well as other information requested by the insurer to determine eligibility, benefits, and claim status.Rock Therapeutic Services therapists will not discuss a child’s diagnosis, session, progress, and behavior with the child’s tutors, friends, or nannies without the parent’s written consent.We may communicate with client’s parents and/or guardians via email, phone and mail.FORMSThe following forms must be reviewed and completed prior to therapy services:RegistrationDevelopmental HistoryConsent for Private TherapyAllergy/Diet RestrictionReferral from your physician, if requiredIn addition, copies of current Individualized Education Plans (IEPs), evaluations, re-evaluations, physician reports, and progress reports are helpful in therapy planning and may be required by insurers.CONTACT INFORMATIONIf you change your insurance, address, phone number or e-mail please let our staff know. We will update your file immediately.We can be contacted by phone: 425.358.7160 or by email: [email protected] as needed.Policy and Procedures – Adult ClientIn order to reduce confusion and misunderstanding between our clients and Rock Therapeutic Services, we have adopted the following policies. If you have any questions about the policies, please discuss them with the clinic director, Adrienne Rock, or the Office Manager, Storch. We are dedicated to providing you with the best possible care and service and regard your complete understanding of these responsibilities as an essential element of your care and treatment.FINANCIAL RESPONSIBILITYRock Therapeutic Services is currently a preferred provider in the Premera, Regence, Aetna, Cigna, First Choice, Molina, and Kaiser-PPO insurance networks. Please refer to your benefits handbook or contact your insurance company to determine whether or not speech-language therapy is a covered service.Rock Therapeutic Services may verify the client’s benefits as a courtesy. Quoted benefits are not a guarantee of benefits, the client is ultimately responsible for verifying their own insurance benefits.Rock Therapeutic Services will submit insurance claims to the insurance company on the client’s behalf.Not all of Rock Therapeutic Services are covered by insurance. Meetings, consultations, and absences that do not conform to our cancellation policy are not covered services and will not be billed to insurers.Insurance claims can take 2-4 weeks to process. Rock Therapeutic Services will send you a monthly invoice for all remaining Patient Liability as shown on the Insurance Explanation of Payment.Payment is expected within 30 days of the invoice date. After 30 days the account is subject to collections.Please note that co-payment and cash payer fees are due at the time of service.We currently accept cash, check, Visa, Mastercard, and American Express. Please make checks payable to Rock Therapeutic Services. There will be a $34.00 service fee for all returned checks.The client is ultimately responsible for all charges of rendered services. If the insurance company determines that the services are not a covered benefit the client will be billed as a Cash Payer.If the client fails to disclose that they have a secondary or tertiary insurance plan, whether commercial or medical plan, they are responsible for all charges of rendered services not covered bu the primary insurance.Provider One/ Apple Health Clients – Rock Therapeutic Services does not submit claims to provider one or Apple Health or one of their managed care plans (except molina ) By signing this form you agree to pay out of pocket for all services rendered.FEE SCHEDULECall office for more information.CANCELED/MISSED APPOINTMENTS POLICYNon-Emergency: 24 Hours Notice This includes anything that is not designated by “emergency “ (see below) such as pre-planned doctor appointments, family events, parties, etc. The session must be canceled with 24 hours notice or it will be subject to a $75 fee. If cancellations become excessive for non-emergency purposes, then the client may lose his/her weekly slot in the therapy schedule.Emergency: Cancel by 10am Emergency cancellations are due to client illness, illness of a family member, or other unforeseen circumstances. These sessions must be canceled by 10am on the day of therapy or it will be subject to a $75 fee.Inclement Weather: Cancel by 10am When a storm is expected, or the roads are dangerous the office usually closes. It is understood that some clients may live far away, and while the office may not be closed, you may choose to stay home with your child. In this case you must follow the procedure for EMERGENCY cancellations and call by 10am that day if you think you would prefer not to travel or you may be billed a $75 fee.ALLERGIES / DIET RESTRICTIONSWhen you register for therapy, you will fill out an Allergy/ Diet Restrictions form. This form is kept in your file which is present during every therapy session. It is crucial for every client to have this form filled out even if you have no allergies. If you have food preferences or diet restrictions please make sure this is noted on the form. If you have not filled out this form or need to make changes please do so as soon as possible.OBSERVATIONS / REPORTSOther professionals, therapists, etc. are welcome to observe our therapy. We do ask for notice if someone other than family wants to observe.If you would like a formal report written about your therapy, please ask your therapist via email or in writing. Please allow 2 weeks for this report to be completed. If you would like the report to be sent out to other professionals please indicate that in your request.CONFIDENTIALITYRock Therapeutic Services will keep all personal, medical, and insurance information confidential. Client information will only be released upon receipt of a signed and dated Healthcare Information Release form. Consent for a release of information may be withdrawn by the client at anytime with a written notice signed by the client.A copy of all evaluation and progress reports will be given to clients, family, or guardians as appropriate. Additional copies will be distributed to those persons with authorization based on the Healthcare Information Release form on file.If a client has requested that their insurance company be billed for therapy services, information will be shared with the client’s insurance company as needed to submit claims for services provided, as well as other information requested by the insurer to determine eligibility, benefits, and claim status.We may communicate with clients via email, phone and mail.FORMSThe following forms must be reviewed and completed prior to therapy services:RegistrationAdult Case HistoryConsent for Private TherapyAllergy/Diet RestrictionReferral from your physician, if requiredIn addition, copies of current evaluations, re-evaluations, physician reports, and progress reports are helpful in therapy planning and may be required by insurers.CONTACT INFORMATIONIf you change your insurance, address, phone number or e-mail please let our staff know. We will update your file immediately.We can be contacted by phone: 425.358.7160 or by email: [email protected] as needed.Policy & Procedure Signature** by checking this box and typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature.*Date* MM slash DD slash YYYY Consent for Private TherapyI consent for* My Child MyselfName*, to attend private speech and language therapy services in the office of Rock Therapeutic Services LLC. I give permission for my child’s/my own therapy program to follow any current communication goals, as well as those determined necessary by the clinician. I have read the furnished Policy and Procedures information and accept the terms stated within.Consent Signature** by checking this box and typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature.*Patient’s Name (if 18 or older) or Guardian’s Name (if patient is 17 or younger)** by checking this box and typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature.*Date* MM slash DD slash YYYY Untitled
