Kidz Therapy



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______________________________

Child’s Name

Kidz Therapy Services, PLLC

POLICIES AND PROCEDURES

PARENT ACKNOWLEDGEMENT FORM

I have received a current copy of Kidz Therapy Services Policies and Procedures.

By signing below, I acknowledge that I have read and will comply with all policies and procedures,

including the Sick Child and Waiting Room Policy.

Since policies and procedures are subject to change, I acknowledge that revisions may occur. All such changes will be communicated to me through official notices. I understand that all revisions supersede, modify or eliminate existing policies.

______________________________ _______________

Parent Signature Date

_________________________________________________

Email Address

( I agree to have another therapist cover my child’s session.

( I do not agree to have another therapist cover my child’s session.

.

________________________________________________________________________________ FOR OFFICE USE ONLY:

← Acknowledgement Form ( Email Consent Form

( Consent to Talk to Teacher

← Sick Child Policy ( Allergy Form: __________________________

← Emergency Information Form ( Medicaid Parental Consent Form

← Rx: ( ST ( OT ( PT ( Alternative Signature Form________________

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Welcome at Kidz Therapy Services we look forward to working with you and your child. There are several policies and procedures that we would like to review at this time to ensure a positive experience for all.

Attendance/General Policies

-Consistent and timely attendance is necessary for your child’s progress. If you miss 3 consecutive sessions or more than 25% of the scheduled sessions in any month your appointment time is not guaranteed. For example, if your child receives therapy 2 x 30 weekly, and is absent for 2 sessions without receiving make-ups within that month, we will contact you regarding a change of provider or time. Please inform us of any medical or family emergencies so other arrangements can be made. Kidz Therapy reserves the right to cancel these services at their sole discretion.

-If you are unable to keep your child’s scheduled appointment, you must notify your provider prior to your appointment. If your child’s session is cancelled for whatever reason, your child’s therapist will contact you prior to your next session to schedule a make-up session if their schedule permits.

-Make-ups must occur within two weeks of the missed session. Only one make-up session per week is allowed. The same service cannot be provided two times in one day even if your child has two different therapists (no make-ups same day as regular sessions). There are no make-ups allowed for services that are provided five days per week.

-Rescheduled sessions can be provided for legal holidays within the same week as the holiday, only if therapist schedule permits.

-You or a designated caregiver (18 years or older) must be on site at all times while your child is receiving therapy.

-You or a designated caregiver (must complete Alternate Signature form) must sign the therapist’s log notes after each session. Do not sign blank therapy log notes.

Therapy Specifics

- No services can begin until we receive a copy of your child’s IEP and STAC form from the school district. Appointment times will not be held if receipt of IEP and/or prescription is delayed.

-Occupational and physical therapy cannot begin until a doctor’s prescription is obtained.

-You must complete, sign and return all included forms to your child’s provider at the first session.

-If services are not provided at home, parents/guardians are encouraged to send a notebook/folder to therapy with their child in order to keep a record of their work, progress reports, home programs/activities, etc.

Record Access

All information in your child's file is confidential. You as the parent or legal guardian have the right to access the file at any time. If you need any records from your child's file, you may call the Preschool Evaluation Coordinator at 516-747-9030 to request a copy of your child’s records. At that time a written request must be submitted.

Moving – From one District to Another District

You must notify Kidz Therapy one month prior to moving from one district to another district, to ensure no lapse in services. If Kidz Therapy is not notified, parents will be financially responsible for any services rendered after the move. You must withdraw from your current school district and register at your new school district (bring current IEP) as soon as possible.

Sick Policy

In order to avoid spreading germs and re-infecting children and staff, the following guidelines are in effect at Kidz Therapy Services. Your child must be fever free, and/or symptom free of illness without medication for 24 hours. If your child is prescribed antibiotics, they should be on the medication at least 24 hours before resuming services. If your child appears ill during the session, you will be notified and the session will be terminated. We appreciate your cooperation in this matter. The provision of services may or may not be provided at the discretion of the provider.

Delivery of Services

All decisions regarding the delivery of services are indicated in your child’s Individualized Educational Program (IEP). Please read the IEP very carefully. If the IEP indicates “Follow the Kidz Therapy Services calendar”, then services may be provided on any day that Kidz Therapy is open. If this is not specifically stated on the IEP, then we must follow your local school district’s calendar. Preschool services (speech therapy, occupational therapy, physical therapy, social skills group, pragmatic group, etc.) cannot be provided on any day listed as holiday or school closed on your school district calendar.

We can, however, attempt to provide individual services on a different day during that week, if schedules permit. Group services cannot be rescheduled. If your local school district’s calendar indicates “Superintendent’s or Teacher’s Conference Day”, services can be provided since the school district is still open.

If you have any questions regarding attendance please feel free to contact us.

Sincerely,

________________________ ___________________________

Judy Mahoney, MA, CCC-SLP Theodora Thomas, MA, CCC-SLP

Clinic Director-Nassau Clinic Director-Suffolk

Suffolk County Department of Health

Office of Children with Special Needs

Preschool Special Education Program

Medicaid Consent Form

Dear Parent/Guardian of: ______________________________ Child’s SS# / CIN# ____________________

This is to ask your permission (consent) to bill your or your child’s Medicaid Insurance Program for special education and related services that are on your child's Individualized Education Program (“IEP”). This consent allows the School District/Suffolk County to bill for covered health-related services and to release information to the School District’s Medicaid billing agent for that purpose.

I have received with this Medicaid Consent Form separate written notification from the School District or IEP service provider that explains in detail my federal rights regarding the use of public benefits or insurance to pay for certain special education and related services.

I understand and agree that the School District/Suffolk County may access Medicaid to pay for special education and related services provided to my child.

I understand that providing consent will not impact my or my child’s Medicaid coverage. Upon request, I may review copies of records disclosed pursuant to this authorization. Services listed in my child’s IEP must be provided at no cost to me whether or not I give consent to bill Medicaid. I have the right to withdraw consent at any time and the School District must give me annual written notification of my rights regarding this consent.

I also give my consent for the School District or Suffolk County or IEP service provider to release the following records and information about my child to the State’s Medicaid Agency for the purpose of billing for special education and related services that are in my child’s IEP:

|-- Records and service information that likely will be shared -- |

|Prescriptions |Service Provider Attendance |

|Referrals |“Under the Direction of” Certification |

|Treatment Logs |“Under the Supervision of” Certification |

|Individualized Education Program - IEP |“Under the Direction of” Logs |

|Calendar and Attendance Records |“Under the Supervision of” Logs |

|Bus Logs |Other unnamed documents needed to support Medicaid claims |

I give my consent voluntarily and understand that I may withdraw my consent at any time. I also understand that my child’s right to receive special education and related services is in no way dependent on my granting consent and that, regardless of my decision to provide this consent, all the required services in my child’s IEP will be provided to my child at no cost to me.

Print Parent/Guardian Name: _____________________________________

Parent/Guardian Signature: _____________________________________ Date: ______________________

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CHILD EMERGENCY INFORMATION

Please be sure to maintain a record of the following information for each child you provide services to, through Kidz Therapy Services. This information should be kept with you while you are providing services, in case of emergency and a copy returned to the Kidz Therapy Preschool Coordinator.

Child’s Name: __________________________________________________________

Child’s Home Address: ___________________________________________________

Child’s Home Phone: ____________________________________________________

Mother’s Name: ___________________ Father’s Name: ______________________

Mother’s Cell: _____________________ Father’s Cell: _________________________

Mother’s Work #: __________________ Father’s Work #:______________________

Mother’s Email: ___________________ Father’s email: _______________________

Guardian Name/Relationship: ______________________________________________

Guardian Cell: ____________________ Guardian Work: ________________________

Medical Alerts Please list any medical conditions (asthma, diabetes, seizures, etc) your child has:

________________________________________________________________________________

________________________________________________________________________________

Allergies -Please list any allergies (foods, latex, etc.) your child has – please be specific:

________________________________________________________________________________

It is your responsibility to notify each therapist of your child’s allergies and/or medical conditions/alerts. If there is a change in medical status of your child, please notify the office immediately. If any allergies are indicated, attach documentation including identification of the allergy, prevention of exposure and plan to treat an allergic reaction.

Emergency Contact (other than parent or guardian) Name: _________________________________

Phone: ______________________________ Email: ____________________________________

Pediatrician Name/Phone: ________________________________________________

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ALLERGY PLAN FORM

To be filled out by Parent and Provider:

Child’s Name: ______________________________________ DOB: ______________

Known Allergy(ies): ____________________________________________________

______________________________________________________________________

Child’s typical reaction to exposure to allergen: ____________________________

Indications that child is having an allergic reaction: _________________________

______________________________________________________________________

In case of emergency, provider will:

1. ___________________________________________________________________

2. ___________________________________________________________________

3. ___________________________________________________________________

4. ___________________________________________________________________

Name of Person(s) to be contacted: ______________________________________

Phone #: ______________________________________________________________

________________________________ _______________________________

Signature of Parent Signature of provider

Date: ________________________ Date: ___________________________

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Parental Consent to Use E-mail to Exchange Personally Identifiable Information

Parent’s Name: ___________________________________________

E-mail Address: ___________________________________________

Child’s Name: _____________________________________________ DOB: ______________________

At your request, you have chosen to communicate personally identifiable information concerning your child's treatment by e-mail without the use of encryption. Sending personally identifiable information by email has a number of risks that you should be aware of prior to giving your permission. These risks include, but are not limited to, the following:

• E-mail can be forwarded and stored in electronic and paper format easily without prior knowledge of the parent.

• E-mail senders can misaddress an e-mail and personally identifiable information can be sent to incorrect recipients by mistake.

• E-mail-sent over the internet without encryption is not secure and can be intercepted by unknown third parties.

• E-mail content can be changed without the knowledge of the sender or receiver

• Backup copies of e-mail may still exist even after the sender and receiver have deleted the messages.

• Employers and on-line service providers have a right to check e-mail sent through their systems.

• E-mail can contain harmful viruses and other programs.

Parental Acknowledgement and Agreement

I acknowledge that I have read and understand the items above which describe the inherent risks of using e-mail to communicate personally identifiable information. Nevertheless, I, __________________________________________

Authorize ________________________________whose email address is _________________________to communicate

with me at my email address, ___________________________, concerning my child's participation in the EIP (Early Intervention Program), CPSE or CSE. including but not limited to communication, regarding service delivery, his/her progress of the IFSP or IEP and any other related matters. I understand that use of e-mail without encryption presents the risks noted above and may result in an unintended disclosure of such information.

(Optional) In addition, I give permission for members of my child's treatment team to communicate personally identifiable information concerning my child with each other using unencrypted e-mail. Team members who I give permission to use unencrypted e-mail to communicate with each other about my child include:

(1)___________________________________with the e-mail address _______________________________________

(2)___________________________________with the e-mail address _______________________________________ (3)___________________________________with the e-mail address _______________________________________

(4)___________________________________with the e-mail address _______________________________________

(5)___________________________________with the e-mail address _______________________________________

Parent's Signature:_____________________________________________ Date________________________

Suffolk County Department of Health

Preschool Special Education Program

PARENT/GUARDIAN CONSENT FOR ALTERNATE VERIFICATION SIGNATURE

I, ________________________________, parent/guardian of ________________________give (Parent/Guardian’s Name Printed)

permission for:

Please all who will be able to sign – Day Care Staff, Teacher, Caregiver, etc. (must be over18)

1) _______________________________________ Title: ______________________________

2) _______________________________________ Title: ______________________________

3) _______________________________________ Title: ______________________________

_________________________________________ _______________________

(Parent/ Guardian Signature) (Date of Signature)

I, ______________________________ hereby withdraw the above permission as of

(Print name of Parent/Guardian)

__________________.

(Date of Withdrawal)

______________________________________ ________________

(Signature of Parent/Guardian) (Date)

SUFFOLK COUNTY DEPARTMENT OF HEALTH

OFFICE OF CHILDREN WITH SPECIAL NEEDS

Preschool Special Education Program

PRESCRIPTION/RECOMMENDATION FOR PRESCHOOL SERVICES

Student’s Name: ____ DOB: _______________ CIN: _______________

School/Provider: Kidz Therapy Services, PLLC District: ___________________

(Agency, Center Based School or Individual Provider)

The child named above is recommended for the following service(s). Services when provided will be in accordance with the Individualized Education Program designed by the Committee.

Period of Service: School Year 7/1/18 - 6/30/19

Diagnosis (ICD-10 code) REQUIRED

You must provide the MOST SPECIFIC ICD CODE(S) for each service checked.

|Service/Therapy |

|Please use an ICD-10 code for each service selected |

| OT ICD-10 Code ___________________ |

|PT ICD-10 Code ___________________ |

|Speech ICD-10 Code ___________________ |

|Psych Co* ICD-10 Code ___________________ |

|NU** ICD-10 Code ___________________ |

*Psych Co = Psychological Counseling Services

*NU= nursing services (In addition to the prescription, a specific Dr.’s order with detailed instructions is required).

Physician/Physician’s Assistant/Nurse Practitioner/SLP Information:

(please print or use stamp):

|Name: | |

|Address: | |

| | |

|Phone Number: | |

|License # (REQUIRED) | |

|NPI # (REQUIRED) | |

| Medicaid # (Optional) | |

_________________________________________________ _______________

Signature of Physician/P.A./Nurse Practitioner/SLP Date Signed

Must be hand written signature; STAMPED SIGNATURE WILL NOT BE ACCEPTED

Note: Medicaid requires that all services recommended by a Physician, Physician’s Assistant, Nurse Practitioner or Licensed Speech Pathologist must be signed prior to or on the start date of services.

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Parent Authorization to Speak to Student’s Teacher

Date: _________________

RE: __________________ DOB: __________

As the parent/guardian of _______________________, I hereby authorize _____________________ to speak/contact my son/daughter’s teachers and/or therapists to obtain further information regarding my child.

__________________________ _______________

Parent’s Signature Date

SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES

DIVISION OF SERVICES FOR CHILDREN WITH SPECIAL NEEDS

PRESCHOOL PROGRAM

Suffolk County Ethics Policy

Provider and Family Agreement for Related Services

Developed by the Suffolk County the Professional Ethics Subcommittee and the LEICC Quality Assurance Subcommittee

As a provider of services to children in your municipality and school district Preschool Program, I am bound by a Code of Professional Ethics. It is important that the families of the children I provide services for understand the professional standards that are incorporated in this code and that we enter into an agreement to assure that the standards are followed.

I will:

• Provide services to the best of my ability based upon my training and credentials;

• Maintain all information to protect the privacy of your child and family;

• Make every effort to follow the schedule for service provision;

• Make up missed sessions, whenever possible, within 10 working days of the missed

session;

• Advise you ahead of time if I am going to be absent for an extended period of time and

call ahead of time if sickness prevents me from providing a daily service;

• Maintain accurate records of the services provided and bill only for those services

provided;

• Provide you with accurate reports of your child’s progress;

• Not engage in non-emergency cell phone and/or text conversations during service

provision;

• Work cooperatively with other members of the treatment team;

• Work with you and other family members in developing strategies you can use to

enhance your child’s development.

Please understand that the provider must comply with the following professional standards:

I am:

• not allowed to work for you in any capacity other than to provide therapy to your

child as authorized on the IEP.

• not allowed to be left alone with your child. A person over the age of 18 must be

present in your home at the time I provide services.

• not allowed to transport you or your child.

• not allowed to accept gifts or meals.

• not allowed to be involved with you in personal activities such as birthday parties or

family events.

• not allowed to recommend changes in services for which the provider cannot provide

appropriate documentation to substantiate that recommendation.

• required to report any suspicion of child neglect, maltreatment or abuse as directed

under Suffolk County Department of Health Services Policy and Procedure, Child

Abuse and Maltreatment Reporting Process, Revised 07/16/04.

I have read this agreement and understand the professional boundaries that my provider is required to follow.

Name of Child: __________________________________________

_______________________________ ____________________________ ________________

Name of Parent/Guardian (please print) Signature of Parent/Guardian Date

______________________________ ____________________________ ________________

Name of Therapist (please print) Signature of Therapist Date

Rev.10-13

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SICK CHILD POLICY

In order to avoid spreading germs and re-infecting children and providers, the following guidelines are in effect -

➢ Child must be fever - free for 24 hours.

➢ Vomiting/diarrhea - child must be symptom - free for 24 hours.

➢ If your child is prescribed antibiotics, they should be on the medication at least 24 hours before resuming services.

➢ Infectious diseases including, but NOT limited to, strep, pink eye, lice, and ringworm - child must have a doctor’s note before he/she can return for therapy.

➢ Broken bones/severe sprains/stitches/or any medical procedure - child must have a doctor’s note before he/she can resume therapy.

➢ If your child is sick, call the provider 24 hours ahead of time, or as soon as possible. Make ups will be provided according to therapist’s availability.

Remember, you are the Parent and if your child is sick they need rest and recuperate. Children do not benefit from services when they are not feeling well.

We appreciate your cooperation in this matter.

KIDZ THERAPY/GEK THERAPEUTIC RESOURCES STAFF

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