Monday, July 30, 2018

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Dear Parent/Guardian: Enclosed please find copies of Country Kids, Inc. intake forms for request of Physical and Occupational Therapy. Included in your packet you should find: ƒ Privacy Notice (information regarding the handling of personal health information) ƒ Intake Form ƒ Parent Questionnaire ƒ Policy/Procedure for Admitting a Child into Services ƒ Billing Policies and Procedures ƒ Service Agreement ƒ Consent Form ƒ Consent to Video and/or Photograph ƒ Authorization to Provide Medical Treatment All Families: Before your child receives services at Country Kids, Inc. all documents must be reviewed, completed as instructed, signed, and returned to our administrative staff. If you have received your packet via mail, please complete the intake and service agreement and return completed forms to our office with a copy of insurance cards (front and back). Please complete all forms completely and thoroughly to prevent delays in initiating programming. Administrative staff will call to go over coverage and schedule the evaluation once the paperwork is reviewed. Hippotherapy/Therapeutic Riding: If you are interested in Hippotherapy or Therapeutic Riding, please contact Exceptional Equestrians directly at (920) 347-3174 or via email at lkpediatrics@aol.com. Hippotherapy is no longer provided as part of OT/PT due to changes in third party reimbursement policies. Please see the website, www.exceptionalequestrians.org for more information and to download the forms to participate. If you have any questions regarding Country Kids, Inc. policies or procedures, please call Lisa Kafka, OTR at (920) 339-0700. Sincerely, Lisa Kafka, OTR, C/NDT, HPCS Administrator, Country Kids, Inc.
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