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Welcome to Therapy Specialists!The purpose of this letter is to provide you with some helpful information to prepare you for your first visitto the facility.Prior to your evaluation being scheduled, your primary insurance will be verified and if necessary, authorizationobtained. If there is secondary insurance that also will require verification and authorization, it is suggested thatyou call the Member Service department at your insurance company and verify what your responsibilities maybe regarding copays, deductibles, referrals, etc. Please remember that benefits quoted are not guarantee of payment per your insurance.The scheduler will call to schedule the patient's evaluation and subsequent session. At that time, you shouldhave a prescription from your physician to evaluate and treat yourself and/or dependent. Any questionsregarding the scheduling of evaluations should be directed to the scheduler at (619) 501-9755.When you arrive for the evaluation, please come to the Reception Desk in the outpatient area and have with you:1. The script from your physician to evaluate and treat.2. Your insurance card.3. Any co-pays or referrals as required by your insurance company.4.Copy of driver’s license of the parent or legal guardianPlease have all of the above items with you when you arrive or it will be necessary to rescheduleyour appointment.After the evaluation has been completed, the therapist will discuss with you a treatment program.If you have any questions, or if I can be of any assistance to you, please call me at (619) 501-9755,or email: libertystation@therapyspecialists.netWe look forward to seeing you.Delphine Roy, PTClinic Directorwww.therapyspecialists.net

PATIENT REGISTRATION FORMPLEASE PRINT CLEARLY AND SIGN BELOWName (Last): (First): M.I.: Suffix:Home Address:CityStreet addressZipStateHome Phone: ( ) Work Phone: ( )Other Phone: ( ) Email:Social Security #: Birth Date: Age: Sex: MDriver’s License #:Status:SingleMarriedDivorcedStudent(circle one):WidowedNoSeparatedFull TimeFPart-TimeDomestic PartnerMinor ChildEmergency Contact: Relationship: Ph: ( )How do you prefer to receive your statements (circle one):EmailFaxMailEmployer: Occupation:Employment (circle one):FullPart TimeNot WorkingRetiredAddress: Ph: ( )Street addressInjury Type:WorkAttorney Involved:CityAutoYesHomeStateZipOtherDate of Injury:No Attorney Name: P: ( )Attorney Address: Fax: ( )Street AddressCityStateZipReferring Physician (if applicable): P: ( )Who may we thank for your referral other than your doctor?**Patient Signature: Date:All professional services rendered are the ultimate responsibility of the patient.INSURANCE INFORMATION (Please Complete)Primary Insurance Policy # Effective DatesInsured Name Social Sec # DOBSecondary Insurance Policy # Effective DatesInsured Name Social Sec # DOBHave you applied for Medi-Cal services in the last 6-12 months?YesNoNOTICE TO CONSUMERS Physical Therapists are licensed and regulated byThe Physical Therapy Board of California (CPTA).Ph. (916) 561-8200 www.ptb.ca.govwww.therapyspecialists.net

CONSENT FOR TREATMENT OF A MINOR: I, the undersigned, do agree to give my consent forTherapy Specialists to provide therapy care and treatment considered necessary and proper forthe minor patient’s condition. As parent and/or legal guardian, I authorize Therapy Specialists totreat the minor patient named in the attached forms while I am not present.Parent/Guardian Signature DateASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize Therapy Specialists to furnishinformation to insurance carriers concerning this treatment and I hereby assign all payment forservices rendered.WORKERS COMPENSATION CLAIMS: If you claim Workers’ Comp benefits and are subsequentlydenied such benefits, you may be held responsible for the total amount of charges for servicesrendered to you.CANCELLATION AND NO-SHOW POLICY: We require 24 hours’ notice in the event of acancellation.The charge for cancellation without proper notice is 25. This charge will not becovered by insurance, but will have to be paid by you personally prior to receiving additionaltreatment.FINANCIAL POLICY: We bill your personal insurance carrier solely as a courtesy to you. You areresponsible for your bill. We require that arrangements for payment of your estimated share bemade today. If your insurance carrier does not remit payment to us within 60 days, the balanceowed will be due in full form you. In the event that your insurance company requests a refund ofpayments made to us, you may be responsible for the amount of money refunded to yourinsurance company. If any payment is made directly to you by the insurance company forservices billed by us, you recognize an obligation to promptly remit the payment(s) to us. Ifformal collections procedures become necessary you will be responsible for additional costsincurred. Your insurance benefits as quoted to us by your insurance carrier have been reviewedwith you. We assume no liability for any errors made by your insurance carrier in this quotation.We have reviewed these benefits with you and you agree to pay your portion of this bill.Estimated patient payment / co-pay / deductible amount per visit Arrangements for payment of patient’s co-pay/deductible (circle one):WILL PAY EACH VISITWILL PAY WEEKLY IN ADVANCEThe above information has been read and explained to me. I UNDERSTAND MY RESPONSIBILITYFOR THE PAYMENTOF MY ACCOUNT.Patient/Guardian/Responsible PartyDatewww.therapyspecialists.net

Appointment Reminder Consent FormPatient Name:Please complete this form and sign below to give your permission for Therapy Specialists toprovide automatic appointment reminder service by email or by textmessage.PLEASEPRINT CLEARLYStep One:SelectMost Preferable OptionBelowTherapy Specialists may send email messages to confirm my upcoming appointmentsto the following email address:Therapy Specialists may send a text message to confirm my appointments to this cellnumber:Step Two: If you would like text messages instead of email reminders, please indicate your cellphone carrier.**We cannot set your account up to send text reminders without knowing your cell phonecarrier.Please indicate your carrier below if you would like text reminders. Thank you!AlltellAT&TBoost MobileCingularCricket WirelessMetrocallMetroPCSNextelQwestSprint PCST MobileUS CellularVerizonVirgin MobileDeclineSignature of Patient or GuardianDatePatient Name (Print):By my signature I acknowledge receipt of the Therapy Specialists notice of privacy practices.Signature of Patient/Responsible Partywww.therapyspecialists.netDate

Company PoliciesTherapy Specialists would like to welcome you to our facility. We are pleased that you have chosen us toprovide care to your child. The following is a summary of our policies. Please retain this information for futurereference.Appointments: Appointments are scheduled following the initial evaluation. Once scheduled, your child will beseen weekly at the same time unless otherwise specified. We will do our best to accommodate your needs butcannot guarantee your preferred day and time request. If we cannot meet your request, your child will be placedon our wait list and will be notified when it becomes availableDuring your child’s appointment, you are welcome to wait in our waiting room. If you need to leave the clinic forany reason, please make certain that your therapist and the front office has a contact number where you can bereached in case of an emergency. We ask that parents return ten minutes prior to the end of the scheduled session. This will allow the therapist time to review your child’s progress and answer any questions you may have.Parents are required to stay on the premises at all time if their child has a medical condition that requiresspecific medication or emergency care. Parents should never be more than five minutes away from the clinic(including drive time).Attendance: In order for your child to receive the maximum benefit from therapy services, it is important thatyou attempt to keep all scheduled appointments. We understand that there may be times that attendance is notpossible (illness, family emergency). Some insurance companies may deny all sessions if there is a pattern ofpoor attendance on the basis that the services are not medically necessary if missing sessions is not having anegative impact on the child. If you miss a scheduled appointment, please work with the front office to schedulea make up session on subsequent weeks. Appointments missed more than 2 weeks in a row (i.e. for vacations orother reasons) will result in loss of therapy time slot.Your child must attend at least 80% of their scheduled therapy sessions over a two-month period or risk beingremoved from the schedule. If your child is removed from the schedule, you may then call the office at thebeginning of each week to schedule an appointment where a therapist has a cancellation in his/her schedule.In the event of a cancellation for occupational, speech, or physical therapy appointments, Therapy Specialistsrequires 24-hour notice by telephone.Late Cancellations: A cancellation is considered late when the appointment is canceled without 24-hour advance notice or a patient is more than 10 minutes late.No-Show: Failure to show up for your scheduled appointment.A late cancellation or no-show fee of 25.00 will be charged to the patient. You may pay for it by cash or creditcard. As a courtesy, for multiple appointments in the same day, we cap any late or no-show fees at 50/day.These fees are not covered by your insurance.www.therapyspecialists.net

The fee for a late cancellation or no-show may be waived 1 time per case per 6-month period. Emergency latecancellations are accepted only for personal illness, hospitalization, illness of a family member (dependent orcaregiver) or death in the family.Please do not arrive with a fever, sickness, vomiting or any other highly contagious illness. If you or your childarrives ill, you will be dismissed as a late cancel under the policy. You may pay the late cancel or no-show fee bycash or credit card prior to your next appointment.Client Requested Services: These services are provided by a Therapy Specialists team member and are not covered by insurance. These services may include attendance at IEP meetings, parent meetings, meetings withother professionals, and observations at schools. These non-covered services will be billed at the current hourlyrate.Permission to Assist the Restroom: If your child needs to use the restroom during the treatment session, andaparent or legal guardian is not present, you give permission for the therapist to accompany your child to therestroom.Other Clinic Rules1. Children must be supervised at all time while in the clinic space. Please supervise your children while theyare in the waiting area.2. If you choose to leave the clinic during your child’s therapy session, you must be in the lobby 10 minutes priorto the scheduled end time.3. Please no food or drink in the waiting room due to food allergies.4. Per property management at our location, no patients are allowed in the hallway. Please remain inside theclinic lobby. Please avoid running and loud voices so that we do not disturb our neighbors.5. Unless specified by your therapist, please do not bring toys from home into the clinic. We are not responsiblefor any lost or broken items.The undersigned certifies that he/she has read the above and is the patient’s legal representative or is duly authorized by the patient as the patient’s general agent to execute the above and accept its terms.Signature Date:www.therapyspecialists.net