Schedule Appointment with MadeQuest Services

Loading...

First Name *

Last Name *

Phone *

Your E-Mail Address *

Notes to Business (your address or any special notes about your order)

Item	Quantity	Total
Individualized Support Subscription	x $39.99	$39.99 per week
Total: $39.99	Coupon:

Think Again Speak Again Therapy

of MadeQuest Services Corp. Consent, Release, and Acknowledgement

1) I consent to receive mental health and/or speech-language pathology services.

2) I agree to assist in providing complete and comprehensive health information and have supplied up to date records necessary to provide informed quality services outside of a ‘vacuum.’ I consent to release medical records and to continue informing the therapist provider (hereby referred to as ‘provider) in case medical changes are made and as updates occur.

3) For speech-language services, I verify that I have and have supplied a current doctor’s order to receive evaluation and/or treatment. I am aware of the need and agree to update the provider in case of any changes to physicians’ orders, recommendations, procedures, related care, and/or insurance.

4) I am aware that updates will be sent primarily via secure email. No recording, reproduction, modifications, use, and/or licensing of consultation, assessment, and/or therapy content allowed. Reproduction and/or posting of therapy content is strictly prohibited. Madequest Intellectual Property Rights include all content included on this Service, is the property of MadeQuest and protected by United States and international copyright laws. You may not (directly or indirectly) decipher, decompile, disassemble, reverse engineer or otherwise attempt to derive source code, content, underlying ideas or algorithms of any part of the Service, or modify, translate or otherwise create derivative works of any part of the Service. Any modification of content, or any portion thereof, or use of the content for any other purpose constitutes an infringement of trademark or other proprietary rights of MadeQuest or third parties, and any unauthorized use terminates the permission to use the Service. Past, present, and/or future violations are grounds for termination of service. Notice and Take Down Procedures Notice of Claims: If we believe any service, post or information infringes copyright or trademark rights, we may request such content be removed by following the notice and take down procedures of the Digital Millennium Copyright Act (DMCA).

5) I am aware of my duty to pay my insurance company’s, if applicable, family cost participation, not hold provider responsible for insurance company errors or refusals for reimbursements for services rendered, and agree to maintain a zero balance at date of service.

7) For in person visits, I consent to notify the provider of need to reschedule sessions at least 24 hours prior to scheduled service, particularly if I am sick and/or recovering to prevent cross contamination and cancellation fee. No refunds for no call/no shows, for the entire hour is reserved for each patient and provider preps for each appointment with individualized detail. Patients may reschedule virtual appointments online anytime up to two hours prior to appointment start time. You are encouraged to reschedule as there are no refunds for cancelled appointments.

8) I am aware that repeated failure to cancel with prior notice, (not including/to be differentiated from cancellations), constitutes allowance of withdrawal of provider from applicable Individualized Family Service Plan (IFSP), Individualized Education Plan (IEP), and/or plan of care (POC).

9) If applicable, I consent permission to bill my insurance company for services rendered, if applicable.

10) I understand that the number of visits indicated on Plan of Care (POC), the Individualized Service Plan (IFSP), and/or Individualized Education Plan (IEP) is a fluid number, which may be adjusted, dependent upon the performance and needs of the patient. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

11) I will consult my provider as the first line of communication to address my questions and/or concerns regarding patient’s Plan of Care.

12) I hereby attest that the information furnished by me to the provider is true and complete to the best of my knowledge and is furnished in good faith. I fully understand that any significant misstatement in, or omission from information provided could significantly impact relevance and effectiveness of services provided and/or constitute interruption, and/or discontinuation of services. Herein is a statement from you under penalty of perjury that the information supplied is accurate. I release from liability any persons or entities that provide information and/or services in furtherance, to the fullest extent allowed by applicable statutes and regulations and am bound by the terms of this contract, which survive beyond discontinuation of services.

13) In the event of an emergency, dial 911. You may reach your therapist via email at therapy@madequest.com in between sessions and via mobile chat for more urgent responses.

14) Session content is completely confidential with the exception that providers may disclose private information without consent in order to protect the patient or the public from serious harm in the event of: a client discusses plans to attempt suicide or harm another person, required to report ongoing domestic violence, abuse or neglect of children, the elderly or people with disabilities, release information if a court order is received, communication among your established and appointed health professionals who may contribute to your health care, appointment reminders and health-related benefits or services may be used and disclose your PHI to contact the patient and remind the patient of an appointment, and if applicable, a client’s insurance company requires a diagnosis be given in order to reimburse you for services rendered and may also request additional information.

15) I am aware of my rights and responsibilities. Nothing in this agreement shall be construed to limit provider from acting within the lawful scope of practice, advocating for the patient, and/or providing treatment. I present this information and arrange for the submission of other information as part of the assessment and therapy process in expectation that confidentiality and privacy will be preserved, and that the information will only be used for services provided, case management, and quality improvement.