M & M HOME CARE: THERAPY ATTENDANCE POLICY

1M & M HOME CARE: STATEMENT OF REVIEW & RECEIPT OF THE PATIENT RIGHTS AND RESPONSIBILITIES > 2THANK YOU FOR CHOOSING M & M HOME CARE. > 3Review Your Entry
PATIENT NAME PATIENT NAME First Last
DATE OF AGREEMENT DATE OF AGREEMENT / MM / DD YYYY

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PATIENT EMAIL
ATTENDANCE AGREEMENT
Thank you for choosing M & M Home Care. Please review this agreement carefully, as it sets forth the understanding between the patient and M & M Home Care regarding the services you have requested and we will provide for you. If you have any questions, concerns or issues about the content of this Agreement please contact us for clarification before signing it.
Your success in rehabilitation is a direct result of regular attendance to your therapy program (not missing any appointments), communicating openly with your clinician, and following your home exercise program as instructed by your clinician.

M & M Home Care has an attendance policy to monitor and ensure that our client’s regularly attend their scheduled appointments for an overall successful therapy program. The policy states that client’s may be discharged from M & M Home Care for any of the following reasons:

1. Three consecutive missed or cancelled appointments
2. Two no shows (i.e. missed appointments without a telephone call/text to cancel)
3. Erratic and or inconsistent attendance

All of the above may adversely affect your recovery and rehabilitation. In the event of any of the above reasons, therapy client’s may be discharged. Client’s physician and case manager will be notified of this discharge. Missed/cancelled visits or other unusual attendance problems are also documented in your medical record. If you are discharged because of attendance problems, any re-admission to our program will require approval by the treating therapist and physician and a new therapy prescription will be required.

A minimum of 24 hours’ notice must be given for any cancellation or to reschedule appointments. Unless there are extenuating circumstances, a 24-hour notice of cancellation is required for all scheduled appointments. Failure to give a 24-hour notice may result in a $120.00 fee
By checking this box I agree that I have read the above Attendance Policy and understand that my cooperation and active participation directly relates to the success of my therapy program.

By checking this box I agree that I have read the above Attendance Policy and understand that my cooperation and active participation directly relates to the success of my therapy program. I agree
ELECTRONIC SIGNATURE
By selecting the "SUBMIT" button, you are signing this Agreement electronically. You agree your electronic signature (hereafter referred to as your "E-Signature") is the legal equivalent of your manual/handwritten signature on this Agreement.

By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature.

Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature.
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PRINTED NAME OF INDIVIDUAL SIGNING ABOVE:
RELATIONSHIP OF INDIVIDUAL SIGNING AGREEMENT
DATE SIGNED DATE SIGNED / MM / DD YYYY
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M & M HOME CARE: THERAPY ATTENDANCE POLICY

M & M HOME CARE: THERAPY ATTENDANCE POLICY

ATTENDANCE AGREEMENT