AGREEMENT AND CONSENT FOR HEALTH CARE SERVICES
Patient's Name: ____________________________________________ ___ DOB: ________________
Phone Number: (_______) _______-_________ __ Gender (circle):
M
F
Address: _______________________________________________ City: __________________ TX
Zip: _________________ Parent‘s Name: _____________________________________________ Physician: ________________________________
Physician Phone: (_________) __________-______________ Emergency Contact NAME (living outside of home): _______________________________
Relationship to patient: _______________________________ Emergency Phone Number: (________) __________-_________________
TYPE OF SERVICE (circle):
Occupational Therapy
Physical Therapy
Speech Therapy
1. TERMS OF AGREEMENT: By signing this agreement, and being the parent or legal guardian of the patient, I give my
consent to KidsCare Therapy to furnish the services listed above to the patient. By signing this agreement, I agree that in the
event that KidsCare Therapy staff is not available to provide the appropriate care, then attempts will be made to provide
service with another employee or contractor. I have the right to refuse backup services, and if I do so then I am
acknowledging that I am capable, willing and able to provide the necessary care for my child. This contract may be cancelled
at anytime by me or KidsCare Therapy upon giving five days’ notice to the other party.
2. MEDICAL CONSENT AND AUTHORIZATION INFORMATION: The patient is under the care of a licensed physician and I
agree that representatives of KidsCare Therapy shall not be liable for any act resulting from following physician’s orders. If
nurses are provided, I authorize the nurses to perform services necessary for patient's care. I authorize any hospital or
physician to furnish KidsCare Therapy, upon request, all records pertaining to the patient’s medical history, services rendered
or medical information to any applicable insurance carrier, or payer source. Per HIPAA (Health Insurance Portability and
Accountability Act of 1996) I give my consent that any medical records/information, and any other information
pertinent to the patient’s care may be faxed, mailed, electronically relayed, orally relayed, or relayed by courier
as may be necessary in providing the best care possible. I also agree that patient medical records, financial
records or any other records that may need to be shared for treatment purposes, payment purposes, health care
or non-health care purposes may be shared as it pertains to the provision of clinical services and payment. I
authorize KidsCare Therapy to bill and collect payment for services rendered to my insurance provider (major medical,
Medicaid or Medicare, or other). I agree to furnish to KidsCare Therapy all information pertaining to the patient's insurance
benefits and keep KidsCare Therapy updated of any changes in coverage. IN THE EVENT THAT THERAPY SERVICES ARE
DENIED, I AUTHORIZE KIDSCARE THERAPY TO ACT ON MY CHILD’S BEHALF AS THE REPRESENTING AGENT FOR APPEALS OR
FAIR HEARINGS.
3. I HAVE RECEIVED COPIES AND UNDERSTAND THE FOLLOWING:
Clinical Supervision of Home Care
Standards of Ethical Practice
Non-Discrimination Policy
Scope of Services
Notice of Information and Privacy Practice
Drug Testing
Patient Grievance Policy
Advance Directives/Living Will
Patient’s Bill of Rights
Medical Power of Attorney
Home & Child Safety
Report of Abuse, Neglect, & Exploitation
4. FINANCIAL RESPONSIBILITY: For Medicaid beneficiaries, KidsCare Therapy will begin services after the physician and
payor approve services, and will not be held financially responsible. For all other beneficiaries, if my insurance declines
coverage, I acknowledge I may be held financially responsible to KidsCare Therapy for 100% of the billable amount of services.
I certify that I have received a copy of this agreement and I grant consent to KidsCare Therapy to provide services. I attest
that all information presented regarding the medical history for the above-stated patient is true and correct to the best of my
knowledge.
____________________________________
________________________________
_____________________
Signature of Parent/Guardian
Printed Name
Relationship to Patient
____________________________________
________________________________
_____________________
KidsCare Therapy Representative
Printed Name
Date