- Consent for Services & Release of Information
- Financial Policy
- Therapy Attendance 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.
As the parent and/or legal custodian of the patient, you have read this consent form and understand the risks involved in rehabilitation therapy for my child and agree to allow your child to fully cooperate, participate in all procedures, and comply with the established plan of care; and hereby authorize the release of my medical information to appropriate third parties; and acknowledge that I have received a copy of the Notice of Privacy act. This consent and acknowledgment are confirmed by your initials and signature on the Acknowledgment of Information form.
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 the continuity of this for our patients. 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 219-764-4888.
Filing Claims with Your Insurance Company: Prior authorization and/or pre-certification for services by your insurance company is not a guarantee of payment services. 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.
We Accept Cash, Checks, And Visa/Mastercard. 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 two hundred dollars ($200.00) 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 two thousand dollars ($2000.00) 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.
I consent to the above financial policy as confirmed by my initials and signature on the Acknowledgment of Information form.
Therapy Attendance Policy
We are pleased you have chosen Jacob’s Ladder Pediatric Rehabilitation for your therapy services. Our goal is to help your child achieve optimal function as quickly as possible. Consistent attendance is critical to progress in therapy. Failing to call to cancel, arriving late for appointments, and frequent cancellations will impact your child’s progress in therapy. Please speak with your therapist if you have a concern about your ability to keep your scheduled appointments.
Jacob’s Ladder’s policy and procedure regarding missed appointments:
- CANCELLATION*: calling with less than 24 hours’ notice that the patient will not attend the therapy appointment. If the patient misses more than 20% of appointments during a rolling three-month period:
- The therapist will call to discuss a plan that better meets your needs (i.e. less frequent therapy visits, different day/time, etc.).
- After this discussion takes place, another cancelled appointment will result in all future appointments being removed from the schedule. You can call in weekly/daily for available appointment slots.
- If scheduled in an available slot, after a second cancelled appointment, the patient will be discharged from services. A management review will be required to resume services.
- NO-SHOW: missing an appointment without calling or arriving too late for the therapist to provide treatment. To provide the most effective services, no-shows will be addressed by:
- The first 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. You can call in weekly/daily for available appointment slots.
- If scheduled in an available slot, after the third no-show, the patient will be discharged from services. A management review will be required to resume services.
*To reduce the 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.
Behavior 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 over time, 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) 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 shadowing and observation hours to students pursuing a degree in related therapy fields. Due to the open layout of our facility, a student may observe more than one child in the clinic at any given time. We reserve the right to have a student observe a therapy session in our facility.