- Consent for Services & Release of Information
- Financial Policy
- Therapy Attendance Policy
- Inclement Weather Policy
- Behavioral Compliance Policy
- Therapy Team Approach & Student Observation Policy
Consent for Services & Release of Information
Rehabilitation therapy (occupational, physical and/or speech therapy) is a patient care service that is provided in order to manage a wide variety of conditions. Services are provided to individuals of all ages regardless of gender, color, ethnicity, creed, national origin, or disability. The purpose of rehabilitation therapy is to treat disease, injury, and disability by examination, evaluation, diagnosis, prognosis and intervention by use of rehabilitative procedures, mobilization, massage, exercises, and physical agents to aid the patient in achieving their maximum potential within their capabilities.
Response to rehabilitation therapy intervention varies from person to person; hence, it is not possible to accurately predict your child’s response to a specific modality, procedure, or exercise protocol. Jacob’s Ladder does not guarantee what your child’s reaction will be to a specific treatment, nor does it guarantee that the treatment will help resolve your child’s condition for which you are seeking treatment.
It is your right to decline any part of the treatment for your child at any time before or during treatment. It is your right to ask your therapist about the treatment they have planned based on your child’s history, diagnosis, symptoms, and examination results.
Consequently, it is your right to discuss the potential risks and benefits involved in your child’s treatment.
Jacob’s Ladder Pediatric Rehabilitation Center, Inc. is committed to providing the best medical care available. It is important to understand that our credit and collection policies are a necessary part of assuring continuity of care. The Financial Policy of Jacob’s Ladder Pediatric Rehabilitation Center, Inc. is as follows:
- IN NETWORK: You are responsible for any co-payments, deductibles, or co-insurance payments at the time of service.
- OUT OF NETWORK: You are responsible for any co-payments, deductibles, or co-insurance payments at the time of service
- SELF-PAY: Our billing department will contact those patients with no insurance to set up payment arrangements.
- PRE-CERTIFICATION/PRIOR AUTHORIZATION: It is your responsibility to notify us if your insurance company requires pre-certification or prior authorization.
- CHANGES IN YOUR INSURANCE: It is your responsibility to inform us of any changes to your account including the insurance carrier, insurance identification number, Medicaid type, address, phone number, etc. Failure to report such changes may result in non-payment for services by your insurance carrier; you are responsible for all charges for services.
- If unusual circumstances make it impossible to meet our billing terms and financial policy, please discuss this matter with our Billing Department at 219-250-3080.
Filing Claims with Your Insurance Company: Prior authorization and/or pre-certification for services by your insurance company is not a guarantee of payment. As a courtesy to you, Jacob’s Ladder will assist you with filing claims with your insurance company. However, your insurance coverage is an agreement between you and your insurer. It is your responsibility to remit payment for charges not covered by your claim and to ensure that your carrier remits payment. If a problem occurs with your claim, you will be required to establish written financial arrangements with our office until your insurance problem is solved.
Electronic Payment Required for All Therapy Services. A credit card will be retained on file at your first visit to charge the agreed upon co-payments/co-insurance/deductible from your Insurance Quote Form. Cash/Check/Credit Card will be accepted for Jacob’s Ladder group/social programs. If a check is returned for non-sufficient funds, a $40 charge will be assessed to the account as well as the bank fee. These fees along with the amount of the NSF check must be paid prior to another appointment being scheduled.
A patient balance exceeding three hundred dollars ($300.00) will result in the patient being placed on hold until the balance is either paid in full or a financial arrangement is established for payment.
An insurance balance exceeding one thousand dollars ($1000.00) will result in the patient being placed on hold until reimbursement is received from the insurance company.
Insurance Authorization And Assignment of Benefits: I hereby authorize Jacob’s Ladder Pediatric Rehabilitation, Inc. to furnish information to my insurance carrier(s) regarding my illness or injury and treatments, and I hereby assign all payments to Jacob’s Ladder Pediatric Rehabilitation Center, Inc. services rendered to my dependent or myself.
I understand if the insurance company sends payment directly to me, I am RESPONSIBLE for turning payment over to Jacob’s Ladder upon receipt of the check. (FAILURE to do so will result in me being responsible for the total balance due on the account in full.)
I understand that I will be charged for any medical record requests made to Jacob’s Ladder. The rate will vary depending on the number of pages and all charges must be paid before records will be released.
I understand that I am responsible for any and all charges, costs, and fees incurred during my evaluation and treatment program at Jacob’s Ladder not covered by my insurance carrier(s). In the case of no insurance coverage, I am responsible for payment in full. If I am unable to pay the balance in full, it is my responsibility to make financial arrangements and make regular payments on my account balance until paid in full. Further, I understand that all delinquent accounts are turned over for collection to a third-party agency if no payment is received for 60 days. My account will then be subject to collection and/or related fees and attorney’s fees, which will be my responsibility.
Therapy Attendance Policy
We are pleased you have chosen Jacob’s Ladder Pediatric Rehabilitation for your therapy services. Our goal is to help you/your child achieve optimal function as quickly as possible. All new and returning patients will receive therapy services until goal attainment or up to 6 months, whichever occurs first. Consistent attendance is critical to progress in therapy.
Each missed appointment affects at least 3 people:
1. You/your child
2. The therapist
3. Another patient waiting for an appointment
Please provide at least 24 hours notice for missed appointments. Failing to call to cancel, arriving late for appointments, and frequent cancellations will slow you/your child’s progress in therapy. Please speak with your therapist if you have a concern about your ability to keep your scheduled appointments.
We define missed appointment in the following ways:
- NO SHOW: missing an appointment without calling more than 2 hours in advance or arriving more than 10 minutes late for the therapist to provide treatment.
To provide the most effective services, no shows will be addressed by:
- A “no show” will result in a call from the therapist to discuss the reason for the missed appointment.
- A second no show will result in all future appointments being removed from the schedule. An email will be sent to the parent/guardian with further instructions for scheduling future appointments. If a child remains unscheduled for more than 7 days, the child will be discharged from services and will require a new referral from the physician for re-assessment and re-establishment of services.
- CANCELLATION: calling with less than 24 hours notice that you/your child will not attend the therapy appointment.
The following reasons are defined as “excused” reasons for cancellation:
- Illness of patient with Doctor’s note*
- Cancellation prior to 24 hours notice with an attempt to reschedule
- Weather emergency or advisory
- Death in the family
*To reduce risk of exposing others to potentially contagious illnesses, please call to cancel due to illness if:
- Patient is less than 24 hours fever free.
- Patient has had episodes of vomiting or diarrhea 24 hours or less prior to appointment.
Frequently non-excused cancellations can limit progress in therapy. If you/your child frequently miss appointments, you may expect a call from the therapist to determine a plan that better meets your need (i.e. less frequent therapy visits, different day/time, transportation assistance, etc.).
Two or more non-excused cancellations within a 12-week period, or 25% of scheduled visits per therapy service, with less than 24 hours’ notice will result in the following:
- The therapist will call with a reminder of the appointment and to discuss reason for missed appointment.
- On the 2nd cancelled appointment, an email will be sent to the family discussing their cancellation history. If available, other appointment times may be offered to better accommodate your schedule.
- On the 3rd cancelled appointment, all pending appointments will be removed from the schedule. An email will be sent to the parent/guardian with further instructions for scheduling future appointments. If a child remains unscheduled for more than 7 days, the child will be discharged from services and will require a new referral from the physician for re-assessment and re-establishment of services.
Inclement Weather Policy
On occasion, it is necessary for Jacob’s Ladder Pediatric Rehab Center to close due to inclement weather.
Jacob’s Ladder Inclement Weather Procedure:
1. Jacob’s Ladder Pediatric Rehab Center will determine closures based on current conditions. If it is determined that Jacob’s Ladder Pediatric Rehab Center will be closed, Jacob’s Ladder will notify all families by telephone and/or text.
2. If a closure occurs, a message will be posted on our Facebook page.
3. In the event that Jacob’s Ladder Pediatric Rehab Center is not closed, if the patient cannot attend the scheduled appointment time due to weather conditions at his/her home, the parent must contact Jacob’s Ladder Pediatric Rehab Center to notify the therapist of the cancellation.
Behavioral Compliance Policy
Maintaining a safe and therapeutic environment for your child is important to us as an organization. However, patients may present with behavioral issues that can be disruptive and/or potentially harmful to themselves or others. If your child presents such behavior while attending Jacob’s Ladder, our staff will do our best to work with them to manage these issues as best as we are able, while at the same time protect the staff and other clients from harm.
If your child presents disruptive/harmful behaviors during their therapy session, you will be notified by our staff as to:
- How we attempted to manage it.
- Whether anyone was injured and if any medical follow up is recommended.
- Possible triggering incidents of the behavior.
- Recommendations for managing the behavior going forward.
If during your episode of care, your child continues to exhibit behavior that is dangerous or harmful to staff and/or other clients, your therapist may recommend discontinuation of services until the behavioral issue(s) is resolved. Your therapist may also recommend alternative therapy options (e.g., ABA therapy, talk therapy) to assist with resolving the issue.
Therapy Team Approach & Student Observation Policy
At Jacob’s Ladder Pediatric Rehabilitation, we take a team approach to providing therapy. As such, circumstances occasionally arise (illness, training, etc.) that necessitate a change in provider for a scheduled appointment. We reserve the right to make these changes without notification provided the time and location of therapy is unaffected.
Jacob’s Ladder Pediatric Rehabilitation partners with universities to promote student education and training. We offer
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.
WHAT IS THIS NOTICE AND WHO WILL FOLLOW IT
Jacob’s Ladder understands that information about you and your health is confidential. We are committed to protecting the privacy of this information. We use and share your health information only as permitted by federal and state laws.
We are required by law to maintain the privacy of your protected health information, to provide you with this Notice of our legal duties and privacy practices with respect to your health information, to notify affected individuals following a breach of unsecured protected health information, and to follow the terms of the Notice currently in effect.
This Notice describes the privacy practices of Jacob’s ladder offices, personnel, including non-employees such as volunteers, who have a need to use your health information to perform their job, and allied health professionals while they are caring for you in Jacob’s Ladder offices. In addition, these entities may share health information for treatment, payment, or health care operations purposes as described in this Notice. This Notice applies to all of the records of your care generated at Jacob’s Ladder, whether made by Jacob’s Ladder personnel or your allied health professional when caring for you at Jacob’s Ladder.
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
The following categories are different ways that we may use and disclose health information. Not every possible use or disclosure in a category is described below.
Treatment. We may use and share health information about you to provide, coordinate, or manage your medical treatment and related services. We may share health information about you with doctors, nurses, technicians, students in health care training programs, or other personnel who are involved in taking care of you. We may also disclose your health information to health care providers outside of Jacob’s Ladder for the purpose of coordinating your care.
Payment. We may use or disclose your information to obtain payment for services provided to you. For example, we may disclose information to your health insurance company or other payer to obtain preauthorization or payment for treatment.
Health Care Operations. We may use and disclose information about you for the purpose
of our business operations. These business uses and disclosures are necessary to make sure that our patients receive quality care and cost effective services. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you.
Business Associates. Some of our functions are accomplished by individuals or companies with whom we contract, called “business associates,” to perform certain specialized work for us. We may disclose your health information to our business associates so they can perform the tasks we have asked them to do.
Electronic Records. Currently, some or all of your health information may be stored in an electronic format. When permissible for valid purposes (e.g., providing treatment or billing for services), your health care providers may access your health information from Jacob’s Ladder office. All access to your health information will be permitted only in a manner consistent with applicable law.
Other Uses or Disclosures. We may also use or disclose your information for certain other purposes allowed by applicable state or federal laws and regulations, including the following:
• For public health activities such as reporting communicable diseases, reactions to medications, problems with products or other adverse events.
• As required by state or federal law such as reporting abuse, neglect, or certain other events.
• For certain health oversight activities such as audits, investigations, or licensure actions.
• For your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety or effectiveness of FDA-regulated products or activities, which include: to report adverse events, product defects or problems, biologic product deviations; to track products; to enable product recalls; to make repairs or replacements; or to conduct post-marketing surveillance, as required.
• In the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized) or certain conditions in response to a subpoena, discovery request or other lawful process.
• When requested by law enforcement, but only as authorized by law, such as to identify or locate a suspect, fugitive, material witness, or missing person.
• To coroners, medical examiners, funeral directors, or organ procurement organizations as necessary to allow them to carry out their duties.
• To avoid a serious threat to your health or safety or the health or safety of others. However, any disclosure would only be to someone who is able to help prevent the threat.
• As allowed by workers compensation laws for use in workers compensation programs.
• If you are a member of the armed forces, we may release medical information about you as required by
military command authorities. We may also release medical information about foreign military personnel to
the appropriate foreign military authority.
• For certain specialized government functions such as intelligence and national security activities.
• If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose medical information about you to the correctional institution or law enforcement official. This
disclosure would be necessary 1) for the institution to provide you with health care; 2) to protect your health and safety or the health and safety of others; or 3) for the safety and security of the correctional institution.
• We may disclose health information to a multidisciplinary personnel team relevant to the prevention,
identification, management, or treatment of an abused child and the child’s parents, or elder abuse and
• In some circumstances, your health information may be subject to restrictions that may limit or preclude some uses or disclosures described in this Notice. For example, there are special restrictions on the use or disclosure of certain categories of information.
Disclosures We May Make Unless You Object. Unless you instruct us otherwise, we may disclose your information as described below:
• To a member of your family, relative, friend, or other person who is involved in your health care or payment for your health care. We will limit the disclosure to the information relevant to that person’s involvement in your health care or payment. In addition, we may disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.
• To contact you to raise funds for Jacob’s Ladder programs and operations. You may opt out of receiving such communications at any time by contacting Jacob’s Ladder Privacy Officer at 219-764-4888.
Uses and Disclosures With Your Written Authorization. Other uses and disclosures not described in this Notice will be made only with your written authorization. You may revoke your authorization by submitting a written notice to privacy contact using the contact information provided later in this Notice. The revocation will not be effective to the extent we have already taken action in reliance on the authorization.
Your Rights Concerning Your Protected Health Information. You have the following rights concerning your health information. To exercise the rights in this section, except for requesting a copy of this Notice, you must submit a written request. You may obtain additional information and instructions for exercising these rights by contacting the Privacy Officer at Jacob’s Ladder:
1595 S. Calumet Road, Suite 3
Chesterton, IN 46304
• Request additional restrictions on the use or disclosure of information for treatment, payment, or health care operations. We are not required to agree to the requested restriction except in the limited situation in which you request we not send information about a health care service or related item to your health plan for the purposes of payment or health care operations if you or someone else pays in full for that service or item at the time of the request and if you notify us in advance (so we do not automatically bill your health plan).
• Request that we contact you in a certain way or at a certain location. For example, you may ask that we contact you at a work phone number or address. We will accommodate all requests that are reasonable for our system capabilities.
• Inspect and obtain a copy of records that are used to make decisions about your care or payment for your care (including an electronic copy if we maintain the records electronically). We may charge you a reasonable cost-based fee for providing the records. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by Jacob’s Ladder will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
• Request that your protected health information be amended. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
1. Was not created by us, unless the person or entity that created the information is no longer available
to make the amendment;
2. Is not part of the medical information kept by or for the entity receiving the amendment request; Is
not part of the information which you would be permitted to inspect and copy; or
3. Is accurate and complete.
Even if we deny your request for amendment, you have the right to submit a written addendum, not to exceed 250 words, with respect to any item or statement in your record you believe is incomplete or incorrect. If you clearly indicate in writing that you want the addendum to be made part of your medical record we will attach it to your records and include it whenever we make a disclosure of the item or statement you believe to be incomplete or incorrect.
• Request an accounting of certain disclosures we have made of your protected health information. The accounting will provide information about disclosures made outside of Jacob’s Ladder for purposes other than treatment, payment, health care operations, disclosures excluded by law, or those you have authorized.
• The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
• Request a paper copy of this Notice, even if you agree to receive it electronically.
Changes to This Notice. We reserve the right to change our Notice of Privacy Practices from time to time, and to make the new Notice effective for all protected health information that we maintain. If we make a material change to our Notice, we will post the revised Notice in our office and on our website. You may obtain a copy of the current Notice by accessing our website at www.jacobskids.org or contacting us as indicated below.
Complaints. You may complain to us or to the Secretary of the U.S. Department of Health and Human Services if you believe your privacy rights have been violated. You may file a complaint with us by notifying us as set forth below. All complaints must be made in writing. We will not retaliate against you for filing a complaint.
Privacy Contact Information. If you have any questions about this Notice, wish to request a copy of the current Notice, or if you want to file a privacy complaint, please contact Jacob’s Ladder at 219-764-4888.