Common use of Insurance Reimbursement Clause in Contracts

Insurance Reimbursement. If you plan to request reimbursement from your insurance, please understand that you should check your coverage carefully and contact your plan administrator with questions. Wheels of Wellness does not contract directly with any insurance company and we do not accept payment from insurance companies. Most families choose to submit their service invoice for reimbursement from their insurance company. Please note Wheels of Wellness will not advise or answer specific questions related to reimbursement or insurance coverage for services. Consent for the Treatment of Minor Children Therapeutic services generally require the consent of both parents prior to providing any services to a minor child. If any question exists regarding the authority of a guardian to give consent for services, Wheels of Wellness will require the guardian to submit supporting legal documentation prior to the commencement of services. Patient Bill of Rights You have the right to: Request and receive full information about the therapist's professional capabilities, including licensure, education, training, experience, professional association membership, specialization, and limitations. Have written information about fees, method of payment, insurance reimbursement, number of sessions, substitutions (in cases of vacation and emergencies), and cancellation policies before beginning therapy. Receive respectful treatment that will be helpful to you. A safe environment, free from sexual, physical, and emotional abuse. Ask questions about your therapy. Refuse to answer any question or disclose any information you choose not to reveal. Request that the therapist inform you of your progress. Know the limits of confidentiality and the circumstances in which a therapist is legally required to disclose information to others. Refuse a particular type of treatment or end treatment without obligation or harassment. Refuse electronic recording (but you may request it if you wish). Request and (in most cases) receive a summary of your file, including the diagnosis, your progress, and type of treatment Report unethical and illegal behavior by a therapist Receive a second opinion at any time about your therapy or therapist's methods. Request the transfer of a copy of your file to any therapist or agency you choose. source: California Department of Consumer Affairs Consent Your signature(s) below indicates that you have read the information in this document and agree to be bound by its terms. By signing this contract, I agree to the terms and conditions outlined above and authorize Wheels of Wellness to provide assessment and/or treatment services to my child and/or family. Furthermore, I agree to the financial responsibility for all services rendered per the terms described above. Client or Child’s name Client or Child’s Date of Birth Parent/Guardian Name Parent/Guardian Signature Parent/Guardian Name Parent/Guardian Signature ALTERNATE MEANS OF COMMUNICATION CONSENT Please initial to indicate that you have read and understand the following: I authorize Wheels of Wellness to email, text or voicemail me regarding appointment times and/or to exchange clinical information, as needed. By initialing this section you are aware of and authorize me to potentially send information that may be read or listened to by unauthorized persons, groups, companies or government agencies that Wheels of Wellness does not control or may not know of reading or listening to such information shared via these modes of communication. Please note: by not authorizing these methods of communication we are left with traditional US mail to communicate information.

Insurance Reimbursement. If you plan to request reimbursement from your insurance, please understand that you should check your coverage carefully and contact your plan administrator with questions. Wheels of Wellness Xxxxx Xxxxxx does not contract directly with any insurance company and we do does not accept payment from insurance companies. Most families choose to submit their service invoice for reimbursement from their insurance company. Please note Wheels of Wellness Xxxxx Xxxxxx will not advise or answer specific questions related to reimbursement or insurance coverage for services. Consent for the Treatment of Minor Children Therapeutic services generally require the consent of both parents prior to providing any services to a minor child. If any question exists regarding the authority of a guardian to give consent for services, Wheels of Wellness Xxxxx Xxxxxx will require the guardian to submit supporting legal documentation prior to the commencement of services. Patient Bill of Rights You have the right to: • Request and receive full information about the therapist's professional capabilities, including licensure, education, training, experience, professional association membership, specialization, and limitations. • Have written information about fees, method of payment, insurance reimbursement, number of sessions, substitutions (in cases of vacation and emergencies), and cancellation policies before beginning therapy. • Receive respectful treatment that will be helpful to you. • A safe environment, free from sexual, physical, and emotional abuse. • Ask questions about your therapy. • Refuse to answer any question or disclose any information you choose not to reveal. • Request that the therapist inform you of your progress. • Know the limits of confidentiality and the circumstances in which a therapist is legally required to disclose information to others. • Refuse a particular type of treatment or end treatment without obligation or harassment. • Refuse electronic recording (but you may request it if you wish). • Request and (in most cases) receive a summary of your file, including the diagnosis, your progress, and type of treatment • Report unethical and illegal behavior by a therapist • Receive a second opinion at any time about your therapy or therapist's methods. • Request the transfer of a copy of your file to any therapist or agency you choose. source: California Department of Consumer Affairs Consent Your signature(s) below indicates that you have read the information in this document and agree to be bound by its terms. By signing this contract, I agree to the terms and conditions outlined above and authorize Wheels of Wellness Xxxxx Xxxxxx to provide assessment and/or treatment services to my child and/or family. Furthermore, I agree to the financial responsibility for all services rendered per the terms described above. Client or Child’s name Client or Child’s Date of Birth Parent/Guardian Name Parent/Guardian Signature Parent/Guardian Name Parent/Guardian Signature ALTERNATE MEANS OF COMMUNICATION CONSENT Please check the appropriate box and initial to indicate that you have read and understand the following: I I, authorize Wheels of Wellness Xxxxx Xxxxxx to email, text or voicemail me regarding appointment times and/or to exchange clinical information, as needed. By initialing this section section, you are aware of and authorize me to potentially send information that may be read or listened to by unauthorized persons, groups, companies or government agencies that Wheels of Wellness Xxxxx Xxxxxx does not control or may not know of reading or listening to such information shared via these modes of communication. Please note: note by not authorizing these methods of communication we are left with traditional US mail to communicate information.

Insurance Reimbursement. If you plan to request reimbursement from your insurance, please understand that you should check your coverage carefully and contact your plan administrator with questions. Wheels of Wellness Xxxxx Xxxxxx does not contract directly with any insurance company and we do does not accept payment from insurance companies. Most families choose to submit their service invoice for reimbursement from their insurance company. Please note Wheels of Wellness Xxxxx Xxxxxx will not advise or answer specific questions related to reimbursement or insurance coverage for services. Consent for the Treatment of Minor Children Therapeutic services generally require the consent of both parents prior to providing any services to a minor child. If any question exists regarding the authority of a guardian to give consent for services, Wheels of Wellness Xxxxx Xxxxxx will require the guardian to submit supporting legal documentation prior to the commencement of services. Patient Bill of Rights You have the right to: • Request and receive full information about the therapist's professional capabilities, including licensure, education, training, experience, professional association membership, specialization, and limitations. • Have written information about fees, method of payment, insurance reimbursement, number of sessions, substitutions (in cases of vacation and emergencies), and cancellation policies before beginning therapy. • Receive respectful treatment that will be helpful to you. • A safe environment, free from sexual, physical, and emotional abuse. • Ask questions about your therapy. • Refuse to answer any question or disclose any information you choose not to reveal. • Request that the therapist inform you of your progress. • Know the limits of confidentiality and the circumstances in which a therapist is legally required to disclose information to others. • Refuse a particular type of treatment or end treatment without obligation or harassment. • Refuse electronic recording (but you may request it if you wish). • Request and (in most cases) receive a summary of your file, including the diagnosis, your progress, and type of treatment • Report unethical and illegal behavior by a therapist • Receive a second opinion at any time about your therapy or therapist's methods. • Request the transfer of a copy of your file to any therapist or agency you choose. source: California Department of Consumer Affairs Consent Your signature(s) below indicates that you have read the information in this document and agree to be bound by its terms. By signing this contract, I agree to the terms and conditions outlined above and authorize Wheels of Wellness Xxxxx Xxxxxx to provide assessment and/or treatment services to my child and/or family. Furthermore, I agree to the financial responsibility for all services rendered per the terms described above. Client or Child’s name Client or Child’s Date of Birth Parent/Guardian Name Parent/Guardian Signature Parent/Guardian Name Parent/Guardian Signature ALTERNATE MEANS OF COMMUNICATION CONSENT Please initial to indicate that you have read and understand the following: I ALTERNATE MEANS OF COMMUNICATION CONSENT I, authorize Wheels of Wellness Xxxxx Xxxxxx to email, text or voicemail me regarding appointment times and/or to exchange clinical information, as needed. By initialing this section section, you are aware of and authorize me to potentially send information that may be read or listened to by unauthorized persons, groups, companies or government agencies that Wheels of Wellness Xxxxx Xxxxxx does not control or may not know of reading or listening to such information shared via these modes of communication. Please note: note by not authorizing these methods of communication we are left with traditional US mail to communicate information.

Insurance Reimbursement. If you plan to request reimbursement from your insurance, please understand that you should check your coverage carefully and contact your plan administrator with questions. Wheels of Wellness Xxxxxxx Xxxxxxxxxx does not contract directly with any insurance company and we I do not accept payment from insurance companies. Most families choose to submit their service invoice for reimbursement from their insurance company. Please note Wheels of Wellness Xxxxxxx Xxxxxxxxxx will not advise or answer specific questions related to reimbursement or insurance coverage for services. Consent for the Treatment of Minor Children Therapeutic services generally require the consent of both parents prior to providing any services to a minor child. If any question exists regarding the authority of a guardian to give consent for services, Wheels of Wellness Xxxxxxx Xxxxxxxxxx will require the guardian to submit supporting legal documentation prior to the commencement of services. Patient Bill of Rights You have the right to: Request and receive full information about the therapist's professional capabilities, including licensure, education, training, experience, professional association membership, specialization, and limitations. Have written information about fees, method of payment, insurance reimbursement, number of sessions, substitutions (in cases of vacation and emergencies), and cancellation policies before beginning therapy. Receive respectful treatment that will be helpful to you. A safe environment, free from sexual, physical, and emotional abuse. Ask questions about your therapy. Refuse to answer any question or disclose any information you choose not to reveal. Request that the therapist inform you of your progress. Know the limits of confidentiality and the circumstances in which a therapist is legally required to disclose information to others. Refuse a particular type of treatment or end treatment without obligation or harassment. Refuse electronic recording (but you may request it if you wish). Request and (in most cases) receive a summary of your file, including the diagnosis, your progress, and type of treatment Report unethical and illegal behavior by a therapist Receive a second opinion at any time about your therapy or therapist's methods. Request the transfer of a copy of your file to any therapist or agency you choose. source: California Department of Consumer Affairs Consent Your signature(s) below indicates that you have read the information in this document and agree to be bound by its terms. By signing this contract, I agree to the terms and conditions outlined above and authorize Wheels of Wellness Xxxxxxx Xxxxxxxxxx to provide assessment and/or treatment services to my child and/or family. Furthermore, I agree to the financial responsibility for all services rendered per the terms described above. Client or Child’s name Client or Child’s Date of Birth Parent/Guardian Name Parent/Guardian Signature Parent/Guardian Name Parent/Guardian Signature ALTERNATE MEANS OF COMMUNICATION CONSENT Please check the appropriate box and initial to indicate that you have read and understand the following: I authorize Wheels of Wellness Xxxxxxx Xxxxxxxxxx to email, text or voicemail me regarding appointment times and/or to exchange clinical information, as needed. By initialing this section you are aware of and authorize me to potentially send information that may be read or listened to by unauthorized persons, groups, companies or government agencies that Wheels of Wellness Xxxxxxx Xxxxxxxxxx does not control or may not know of reading or listening to such information shared via these modes of communication. Please note: by not authorizing these methods of communication we are left with traditional US mail to communicate information.. PHOTOGRAPHY/VIDEOGRAPHY CONSENT