I give permission to PTS staff to provide therapy services and/or administer medical aid, or to seek and have aid provided from a qualified medical professional if the situation requires.

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

Welcome to Pediatric Therapy Services, Inc. (PTS). Beginning in a therapy program is a big step and a real commitment. Our entire staff is committed to providing you and your family with the professional services and timely information that you will need in order to progress in your therapy goals. We also need your commitment of consistent attendance and diligent effort to make our partnership a success. If you must cancel a therapy session, we ask that you call us as far in advance as possible. We feel strongly that consistent attendance is important to the success of your therapy program. We have developed specific procedures to clarify our expectation of your attendance. We ask you follow the procedures listed below. I understand and agree to the following related to attendance of my therapy sessions:

• 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.

I understand that under the Health Insurance Portability and Accountability Act of 1966 (HIPAA), I have certain rights to privacy regarding my protected health information (PHI). I understand that this information can and will be used to:

• 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.