CLINIC POLICY and GUIDELINES

Dear families:

The attendance and financial policies are designed to improve our ability to help all of our patients and to provide complete and consistent treatment for you or your child.

Consistent weekly attendance is a key component to effective therapy treatment. Regular session attendance helps to reinforce skill development and assist in the carryover of skills to settings outside the clinic. The appointments you make with our therapists are reservations and are considered a commitment to your child’s developmental health and our business relationship with you. Missed appointments affect everyone, including you, our skilled staff and other families and clients in need of our treatment. When clients do not show for their appointment or do not give adequate cancellation notice, we are not given the opportunity to reschedule that time with another client who is in need of an appointment.

Our clients are expected to maintain an attendance rate of 90% within a 3 month period. Missed sessions need to be made up within the current treatment plan period. Sessions that are cancelled by the clinic will not be counted towards your attendance rate.

• RESCHEDULING

At MPTC we use a team approach to therapy and believe that rescheduling missed appointments is important for consistency and to help your child achieve their goals. We try to be as flexible as possible with scheduling and appreciate your flexibility too. If your child misses a therapy appointment for any non-emergency reason, we expect that the session will be rescheduled. This might be with another therapist if a desired time is not available with your child’s primary clinician.

• EMERGENCY CANCELLATION

Emergencies arise and we understand. This may be due to personal illness, illness of family member, death in the family, inclement weather, or other unforeseen emergency situations. Please contact MPTC by phone at (763) 595-0812, as soon as possible to report the emergency. **If your child does not go to school or daycare due to illness, they should not attend therapy. Please contact our office to cancel the appointment as soon as possible. You are always welcome to leave a message on our 24-hour voicemail.

• NON-EMERGENCY CANCELLATION

Notice of non-emergency cancellations must be given at least 24 hours in advance and are expected to be rescheduled. This includes all other cancellations not specified as an emergency cancellation such as: vacations, schedule conflicts, medical appointments, etc. You will be charged $75 for late non-emergency cancellations.

• LATE CANCEL WITH FEE

For any non-emergency cancellations, including a no-show, that are made less than 24 hours in advance you will be charged a late cancellation fee of $75.00. This cannot be charged to insurance and is the responsibility of the patient. Fees must be paid in full prior to your next scheduled appointment.

• SUSPENSION OF SERVICES

MPTC reserves the right to suspend therapy services if the patient has missed 10% or more of scheduled appointments in a treatment plan period; or if more than 1 session is missed due to late cancel / no-show; or if there is an outstanding balance over 30 days.

• INSURANCE INFORMATION

MPTC is contracted with many insurance companies and must abide by their requirements and conditions within the contract. Clients are required to inform MPTC within 30 days of any changes in their insurance policy or carrier prior to the change so that benefits can be confirmed. Client/guardian is responsible for payment when services are denied for any reason. We will make every effort to obtain benefit information on your behalf. However, this information is obtained in a good-faith effort and is not ever a guarantee of payment. It is the insurance company that makes the final determination of your eligibility and benefits and you are always responsible for payment of services.

• Copayments are due at the time of service.
• Coinsurance is calculated and also due at the time of service.
• Prior Authorization may be necessary after an evaluation or certain number of visits as required by your insurance company. We will work with your insurance company to get this in place. However, if you change insurance carriers, do not tell MPTC and a prior authorization is required for services, you will be responsible for payment for those denied dates of service.
• BILLING STATEMENT AND PAYMENT

If there is a balance on your account, a statement will be sent on the 1st of each month. The balance is due within 20 days after the statement date unless other arrangements are approved by MPTC management in writing. All payments will be credited to your account on the date it is received in our office. We accept checks, HSA payment and the following credit cards: Visa, MasterCard, Discover, and American Express.

• FEES AND SUSPENSION OF SERVICES

*A late fee of 10% will be imposed on each account that is past due over 30 days.

If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, we will add any of the collection costs or fees which are incurred to your amount due. If we have to refer collection of the balance to a lawyer, any lawyer fees and court costs will be added to your amount due.

*Returned checks by your bank will incur a $20.00 fee and any additional costs from the bank.

*MPTC reserves the right to suspend therapy services if:

• the outstanding patient balance is past due 30 or more days and is greater than $500.00.

Waiver of confidentiality:

You understand if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if the past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.

I give my permission for MPTC to photograph and/or videotape my child, and use said photos/videos for promotional or teaching purposes. The photos may be posted on social media plat forms as well as marketing materials. Check one of the following boxes below.

Mission Statement:

Helping children and adults learn to breathe, eat, speak, move, and BE WELL.

At Minnetonka Pediatric Therapy Center (MPTC), it is expected that all patients, families, caregivers, visitors, and employees ensure a safe, professional and respectful environment.

MPTC employee commitments:

We will conduct ourselves professionally in our work with the highest regard for our patients, families, and visitors. We will hold ourselves and each other accountable for appropriate behavior and be part of the solution.

Responsibilities and behavior expectations for employees and visitors:

• All parents, families, caregivers and visitors should follow visitor policies.

• Anyone with the following symptoms must stay home: fever, upper respiratory infection, dermatitis, gastrointestinal symptoms or exposure to communicable diseases.

• Clothing is required. Clothing with obscene language is not allowed.

• Everyone should show respectful and considerate behavior that does not create a risk, disruption, or threat to others.

• Disruptive language is prohibited. This includes language that is:

Derogatory

Threatening

Profane

Excessively loud

Sexual

• Possession or use of drugs, tobacco in any form, or alcohol on MPTC property is prohibited.

• Physical violence is prohibited and will result in being escorted out immediately.

• Weapons are prohibited on MPTC property and will result in being escorted out immediately.

• Consent is required for photography or recordings of employees, visitors, and patients.

If conduct does not promote a safe environment, the individual will be required to leave. If you have questions about the commitment to a safe environment, please ask to speak to the Executive Director or Clinical Director.

By signing this form, I acknowledge that I have read and understand Minnetonka Pediatric Therapy Center’s Attendance and Financial Policies and Guidelines and agree to adhere to the guidelines and procedures noted above.