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Privacy and Payment Policy Form
Deana Lesher
2026-02-03T16:53:55-06:00
Child's First Name
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Child's Last Name
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Parent's Full Name
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I authorize PEDIATRIC CONNECTIONS or any entity doing business with PEDIATRIC CONNECTIONS, to verify the benefits of our insurance and email us the benefit details.
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Initial
I authorize PEDIATRIC CONNECTIONS to bill my insurance company directly for the covered portion of charges, and I authorize payment of medical benefits directly to PEDIATRIC CONNECTIONS.
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Initial
I authorize PEDIATRIC CONNECTIONS to release medical or other information necessary to process this claim.
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Initial
I understand that the verified estimation of benefits is provided as a courtesy, and does not guarantee coverage. I realize that I am ultimately responsible to know my level of coverage, which includes number of allowed visits.
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Initial
PEDIATRIC CONNECTIONS will submit claims to my health insurance company. I am responsible for payment of my deductible, co-insurance or co-payment, and any charges not reimbursed by my insurance carrier.
(Required)
Initial
It is my responsibility to inform PEDIATRIC CONNECTIONS of any and all changes of insurance coverage during the course of treatment. Failure to do so may result in denial of coverage by my insurance company. If my insurance changes, PEDIATRIC CONNECTIONS will bill my new insurance company, but there is no guarantee they will cover the services.
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Initial
PEDIATRIC CONNECTIONS uses a billing company to process claims and payments. The billing company is of our choice and its employees will have access to protected patient information. This is for the purposes of providing insurance companies with needed information to process claims. Your initials indicate your permission to share protected patient information in order to process payments on your child's behalf
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Initial
I consent to therapeutic treatment, procedures, and patient plan of care to be established after initial evaluation, which is deemed necessary or advisable by PEDIATRIC CONNECTIONS and/or my provider. I acknowledge that an occupational diagnosis is not a medical diagnosis by a physician and neither PEDIATRIC CONNECTIONS nor its therapist claim to be a licensed physician or hold any credentials that may allow them to give medical advice. I acknowledge that no guarantees have been made regarding the outcome of these services, and I am aware that the services require my/my child's participation. I acknowledge that I am personally responsible for my/my child's participation in the services provided by PEDIATRIC CONNECTIONS. Parents will be provided informed consent and education regarding treatment modalities prior to services rendered. In the event of a medical emergency, PEDIATRIC CONNECTIONS has permission to provide care as therapists deem necessary. This includes calling emergency services and/or allowing emergent transportation for proper medical care.
(Required)
Initial
Our clinic may use secure, HIPAA-compliant electronic tools, including automated documentation technology, to assist clinicians in maintaining accurate medical records. These tools are used solely to support treatment and operations and follow strict privacy standards.
(Required)
Initial
I hereby release, discharge and acquit PEDIATRIC CONNECTIONS, it’s agents, representatives, affiliates, employees or assigns of and from any and all liability, claim, demand, damage, cause of action, or loss of any kind arising out of or resulting from my refusal to accept, receive or allow emergency and or medical services, including but not limited to ambulance service, Emergency Medical Technician, physician or urgent care services.
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Initial
PEDIATRIC CONNECTIONS values the education of OT students at various levels. Your treatment session may include observation students, Level 1 or 2 Fieldwork students, but will always be under the guidance and supervision of a licensed therapist.
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Initial
SMS Privacy Policy – This privacy policy governs the manner in which we collect, use, maintain, and disclose information collected from users of our messaging services. We do not share end-user data with third parties. By opting in to our messaging services, you consent to the collection, use and disclosure of your information as described in this Privacy Policy. We do not share end-user data with third parties. Should you require assistance, message HELP and our support team will be with you immediately. You agree to receive informational messages (appointment reminders, account notifications, etc.) from our company. Message frequency varies. Message and data rates may apply. For help, reply HELP for immediate assistance. We respect the rights of our users to opt out of receiving future communications from us. If you wish to be removed from our messaging list and no longer receive communications from us, you can opt out by texting any of the following keywords: STOP, QUIT, END, REVOKE, OPT OUT, CANCEL, or UNSUBSCRIBE. Enter phone number to opt-in.
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Phone Number
Notice of Privacy Policy:
This notice tells you how we collect, handle, and disclose personal health information. If you want to limit our disclosing, please submit your wishes to us in writing. We protect personal health information we collect by maintaining physical, electronic, and procedural safeguards that meet applicable laws. The Protected Heath information we collect about your comes from the following sources: Information received from your physician or other health care providers, from you while providing therapy services, on enrollment forms, assessments, evaluation, or other forms, from other caregivers, insurer, employer or other. We may disclose any of your protected health information to the following entities as long as this information directly relates to health services we provide for you or your child’s individual care. These entities may include doctor, billing services, your insurance company, or other caregivers that bring your child to therapy.
I agree to the privacy policy.
Please indicate below how I may share protected health information with you. Check all that apply:
Mobile phone voice mail
Mobile phone text messages
Home phone voice mail
Work phone voice mail
Email
All commercial insurance and private pay clients (excludes Medicaid):
To streamline our billing process and to more efficiently collect payments, we are mandating a credit card on file to process all patient related balances. All deductibles, co-insurances, co-payments, missed appointment fees, and all other non-covered services will be auto-charged to the credit card on file. A receipt will be emailed to the email address on file. Upon request, an itemized summary report will be mailed showing how the payments have been applied towards the balance. A $20 processing fee will be applied to all declined credit cards so it will be imperative to keep an updated card on file. If you have any questions about this policy please contact Julie Frazier, Billing Administrator at (316) 263-0776 or juliefrazier@medisourcehcs.com
PAYMENT AUTHORIZATION FORM
Required for all non-Medicaid Clients. Please note: If you do NOT have Medicaid, we must have at least 1 credit card on file before we will begin services. Please contact Julie Frazier, Billing Administrator at (316) 263-0776 to place a credit card on file that may be used to pay remaining balances or copays. Services will not begin until an authorized payment is on file.
I have read and agree to abide by the above policies and am aware of the privacy policy. I agree to the Payment Policy/Assignment of Benefits/Authorization to Release Medical Information.
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Initial
First Name
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Last Name
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Signature
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By signing, I agree to have Medisource Healthcare Solutions bill my insurance and/or process my credit card after each visit on behalf of Pediatric Connections OT (when applicable for non-Medicaid clients).
Date
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MM slash DD slash YYYY
Thank you for choosing PEDIATRIC CONNECTIONS for your child’s therapy services.
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