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I give consent for All of Me Therapy, LLC to communicate with me and my therapy providers through non-secured electronic correspondence (email & texting). I acknowledge and agree that information sent via email is not considered secure. Therefore, I agree that All of Me Therapy, LLC has no liability to me for any loss, claim, or damages arising or in any way related to response(s) to any email or other electronic communication.
Parent/Guardian Signature:
Please indicate when each milestone was met:
Is there a history of any of the following?
Does the child: Muscle Tone
Coordination
Please list:
I have read, understand, and agree to the clinic policies listed above. I understand that I am responsible for ensuring payment of services and understand that visits may be terminated, and documentation withheld until payment is received in full. I understand that visits may be terminated at any time by either party and I agree to comply with the policies stated above.
Due to the closure of our practice in March of 2020, because of COVID-19, we adapted our service delivery model to include teletherapy services to maintain continuity of services for our families. We have reopened and are resuming face-to-face services and plan to discontinue most regularly scheduled teletherapy by August 31, 2020. However, in the event of an emergency, extreme circumstances, or another government-mandated closure, we want to provide families with the option of teletherapy to maintain continuity of services. Please indicate your interest in receiving teletherapy if needed:
Telepractice, the act of providing telehealth services, is defined as "the application of telecommunications technology to delivery of professional services at a distance by linking clinician to client, or clinician to clinician, for assessment, intervention, and/or consultation." This means that we can provide therapy services through digital meetings similar to the popular communication system “Skype.” While we do not specifically utilize Skype for the provision of services, the method of delivery would be similar in nature. The therapist and the child would join a computer-based session at the designated therapy time and would work on the same materials as in the office. We term this “teletherapy.”
I , ( parent/guardian ) the legal parent/guardian of ( child’s name ) hereby consent to engage in teletherapy with All of Me Therapy, LLC. I understand that “teletherapy” includes treatment using interactive audio, video, or data communications. I understand that teletherapy also involves the communication of my medical information, both orally and visually.
I understand the following with respect to teletherapy:
Primary Insurance Information
I (Name For Insurance) authorize All of Me Therapy, LLC, to bill (name of insurance company) for services rendered by All of Me Therapy, LLC. I also agree to have any or payments made by said insurance company to be payable directly to:
All of Me Therapy, LLC 8626 Wicker Ave., Suite C Saint John, IN 46373
By signing this document, I also agree to the following statements:
I understand the above information and agree that my health history and related information was completed correctly to the best of my knowledge, and I understand that it is my responsibility to alert All of Me Therapy, LLC of any change in my medical status or insurance coverage.
I, (Cotnact Name), do hereby give consent for All of Me Therapy, LLC to communicate with me and my therapy providers through non-secured electronic correspondence (email & texting). I acknowledge and agree that information sent via email is not considered secure. Therefore, I agree that All of Me Therapy, LLC has no liability to me for any loss, claim, or damages arising or in any way related to response(s) to any email or other electronic communication.
I, (Parent/Guardian Name), Parent/Guardian of (Patient Name) hereby authorize and consent to the use of his/her visual image by All of Me Therapy, LLC for appropriate purposes, including but not limited to: still photography, videotape, electronic and print publications and websites. I give this consent with no claim for payment.
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:
I have also been informed of and given the right to review and secure a copy of All of Me Therapy, LLC Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that All of Me Therapy, LLC reserves the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.
I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.
I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.