CONSENT FOR TREATMENT
I consent and authorize permission for Alpha Kids Shine, LLC and a licensed physical therapist to give rehabilitation and therapeutic treatment to my child/minor. I understand that no guarantees of improvement can be made with physical therapy and with the results of my child. I also understand and am informed that physical therapy can have risks of injury whether mild or serious and I have the right to refuse any procedure or treatment at any time. I have the right to discuss all medical treatments with my licensed physical therapist. I also know that I must inform the physical therapist of any health changes, new medical results, and any precautions or contraindications to therapy treatment.
I hereby acknowledge that I have been made aware of Alpha Kids Shine LLC privacy practices. Alpha Kids Shine, LLC does not share or knowingly share information about you and your family. We also will never use or disclose your child’s private health information without permission from a parent/guardian. When you fill out a form on our website we keep your information to conduct business with you or market additional services. Additional forms on how your information is protected can be made available to you.
AUTHORIZATION TO OBTAIN OR RELEASE MEDICAL INFORMATION
I give my permission to Alpha Kids Shine, LLC to release my child’s health care information to my child’s physician or specialist. I also authorize the release of my child’s medical records (doctor visit notes, history and physical, clinic notes, radiology reports, consultations) to Alpha Kids Shine, LLC, from my child’s pediatrician, specilaist or other health care provider to help the physical therapist better understand my child’s condition and benefit my child’s treatment. I also understand that I do not have to share these records. If I want to take away the permission for my doctor to get these records, I need to talk to my doctor or a staff person and sign a paper.
I understand that payment is due at the time of the treatment session and agree to pay Alpha Kids Shine, LLC the amount billed for the session. I will ask for a superbill to file on my own with my medical insurance if I chose to do so.
If my medical insurance is in-network with Alpha Kids Shine, LLC I will allow them to file for insurance benefits to pay for the care I receive. I understand that Alpha Kids Shine, LLC will have to send my medical record information to my insurance company. When my insurance benefits are filed, I understand I must pay my share of the costs. I must pay for the cost of these services if my insurance does not pay or I do not have insurance.
I understand that all appointments are scheduled in advance. If I need to cancel my scheduled appointment I must call, text or email Alpha Kids Shine, LLC, at least 24 hours before the appointment. By doing this I can provide the opportunity for another child and family a possible appointment time.