Nourish Treatment Day

A whole body integrative approach to optimize feeding, bonding, and overall development and wellness.







-$250 Private Pay Only (Cash, Check or Card Accepted)

(able to provide Superbill documentation for insurance reimbursement)

April 22, 2023

1795 Alysheba Way, UNIT 1204
Lexington, KY, 40509

**First building on the right in the Stonecrest Office Complex

You and your little one!
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Email *
Parent First and Last Name: *
What is your child's name and age? (Ex: Jessica, 8 weeks) *
Who can we thank for your referral? *
Session Time Preference/Availability: (Please select 1-2 options. We will schedule based on first come, first served.) *
Why are you seeking services today? (Ex: feeding, motor, atypical reflexes, sensory, behavior concerns, etc.)
Please describe your birthing experience:
Please describe a typical routine for your baby: (feeding schedule, sleep schedule, etc.)
What do you hope to gain out of this session? *
Is there anything else we should know about you, your child or specific needs you have? 

(Parental stress concerns, upcoming transitions, or environmental factors)

**Note: We are located on the second floor of the building.
Current and/or past feeding therapy or services:
Additional providers on your child's treatment team? (chiropractor, craniosacral therapist, lactation consultant, physical therapist, etc.)
I hereby authorize Kentucky Therapy Solutions and Sunny Day Therapy to render appropriate evaluation and therapy services to the client named above in accordance with state and federal laws. I understand that care will be provided by a qualified, licensed, and trained health professional. I recognize, agree and understand that I have the right to refuse treatment or terminate services at any time.  *
HIPAA Policy - Notice of Privacy Practices. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential.  This Act gives you, the patient, significant new rights to understand and control how your health information is used. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

Treatment means providing, coordinating, or managing health care and related services, by one or more health care providers. An example of this would include a physical examination.

Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collections activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.

Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

We may create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosure to family members, other relative, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
The right to inspect and copy your protected health information. The right to amend your protected health information.
The right to obtain a paper copy of this notice from us upon request.

This notice is effective as of April 14, 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protections have been violated. You have  the right to file written complaints with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the polices and procedures of our office. We will not retaliate against you for filing a complaint.

Please contact the following for more information:

The U.S. Department of Health & Human Services Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
(202) 619-0257
Toll Free: 1-877-696-6775

I acknowledge that I have received a copy of HIPAA Notice of Privacy Practices that fully explains the uses and disclosures they will make with respect to my individually identifiable health information.
Acknowledgement and Assumption of Risk: I understand that I am being asked to carefully read each of the provisions in this form. I acknowledge and agree to have my child receive therapy services from Kentucky Therapy Solutions and Sunny Day Therapy. I acknowledge that there is some inherent risks associated with the use of therapy equipment that cannot be eliminated regardless of the care taken to avoid injuries. I understand the risks and I hereby assert that my participation is voluntary and that I knowingly assume such risks without holding Kentucky Therapy Solutions and Sunny Day Therapy, and/or any employee or independent contractor employed by Kentucky Therapy Solutions and Sunny Day Therapy accountable for any losses, injuries or other damages occurring to the client and/or myself. I further understand that I am fully responsible for my own safety. *
Payment Policy: Thank you for choosing our private practice to serve you. We are committed to providing you with the highest quality care. Please know that the timely payment of your bill is an integral part of our service and as such, this payment policy is an agreement between you and Kentucky Therapy Solutions/Sunny Day Therapy for payment of services provided. By signing this policy, you are agreeing to pay for services provided to you or your family member. By signing this document, you acknowledge that you have received and understand your financial responsibilities to this practice if you choose to receive services.  All therapy fees (including session fees and/or co-pays, if applicable) are due at the time of service. I understand the payment policy and the risks of not adhering to it. *
Client Testimonial Permission Form and Photo Release: I hereby grant Kentucky Therapy Solutions, Sunny Day Wellness, its employees, designees, agents, independent contractors, legal representatives, successors and assigns the absolute right and unrestricted permission to use and distribute my testimonial, or any part of my testimonial. I give consent to Kentucky Therapy Solutions, Sunny Day Therapy or any party authorized by these organizations, to photograph and/or video record my child in connection with his/her therapy, for any purpose subject to the therapist's discretion including but not limited to educational publication, teaching purposes and/or demonstration of progression of his/her skills. *
A copy of your responses will be emailed to the address you provided.
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