This entire consent is valid from the date of my signature until closure of the patient file or until I revoke it in writing.

Immunizing patients against preventable diseases is a critical component of high quality medical care. In order to provide excellent care and a safe medical home for all patients, Pediatric Therapy Services is establishing a vaccination minimum standard.

Policy:

All Pediatric Therapy Services patients should be vaccinated according to the American Academy of Pediatrics endorsed vaccine schedule.

Existing patients who are not currently being vaccinated according to the AAP schedule will be dismissed from our practice.

New patients who are not adhering to the minimum vaccine schedule according to the AAP will not be permitted to begin treatment at PTS.

If patients cannot commit to this minimum vaccination standard, then Pediatric Therapy Services, Inc. will no longer be able to commit to being their pediatric therapy provider.

Once a patient notifies PTS of their decision to refuse vaccination according to the minimum standard, PTS will initiate the process necessary to smoothly transition the patient to another practice.

I understand that I am responsible for notifying Pediatric Therapy Services, Inc. of any changes in my vaccination schedule.

• I understand that consistent attendance of scheduled therapy sessions is critical to improvement and progress. I believe that attending therapy sessions is a commitment I am ready to make.
• I understand that if the commitment becomes difficult for me to meet I will discuss it with the front office and we can work toward a solution.
• I will notify PTS of planned absences or vacations in advance.
• I will phone PTS before my appointment time if I am unable to attend my therapy session. If I do not call, my absence will be considered a “no show.”
• If I “no show” for a scheduled appointment, I will not be placed on the schedule again until PTS receives a phone call requesting an appointment.

• Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations such as quality assessments and physician certifications I received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my PHI. I understand that this organization has the right to change its Notice of Practices from time to time and that I may contact this organization at any time to obtain a current copy of Notice of Privacy Practices.