Thank you for choosing KidSpeak to help meet your child’s communication needs. I realize there are many options from which to choose and I appreciate the opportunity to assist you with this important process.
The New Client Paperwork packet includes important information about my practice including insurance, financial and privacy policies. Please take time to fill out as much information as possible regarding your child’s developmental history as this information can be vital to the direction of the therapy plan. I understand that these forms can be time consuming, however it is important that I have as much information as possible prior to your first visit so that I may provide the best possible service for your child. If your child has any recent evaluations completed by other health professionals (psychologist, IEP, etc.), please bring copies of these with you or may fax them to me in advance.
Once complete, your data is sent to me securely via e-mail.
I look forward to meeting you and your child!
Amy J. Clayman, MA, CCC-SLPLicensed Speech-Language PathologistFL License # SA8719ASHA Certification #firstname.lastname@example.org
Does your child appropriately...:
At times we may need to contact you for appointment reminders or other concerns. Pleasecomplete only the items below that you authorize as a method of contact. Note: Home address, one phone number and one e-mail address are required.
I authorize the release of any payment and medical information necessary to process my or my family member’s insurance claim and related claims. I hereby authorize payment directly to KidSpeak, LLC of the insurance benefits otherwise payable to me for all professional services. I also understand that speech therapy insurance benefits coverage does not guarantee that services will be deemed "medically necessary" as outlined by my plan policy. I understand that KidSpeak will provide all required documentation to Aetna to allow for coverage determination/medical necessity, however I also realize that it is rare that speech therapy services are considered medically necessary.
POLICIES AND PROCEDURES
Appointments: If you must cancel an appointment that you have scheduled, please call immediately. Except underemergency circumstances, all appointments cancelled with less than 24 hours notice will be subject to a $35 service fee. In the event that you arrive late for your appointment, I will do my best to see you, however the appointment may be shortened due to time constraints; the full session fee still applies. Appointment no-shows will be charged the full session rate. Please note that most insurance companies will not reimburse for missed appointments and you will remain responsible for these charges. Please do not bring any child to the clinic that does not have an appointment with us (e.g., siblings), unless you have discussed this in advance.
Fees: I will always inform you of the charges prior to providing any type of clinical service. A schedule of fees can be obtained from my office at any time. Fees apply to various types of services including direct client contact (clinic based or offsite), phone consultations, travel, and consultation with other professionals.
Payment: Person who completes the Party Responsible for Payment section is responsible for payment of all services rendered. Payment is due at the time services are rendered unless you have made other arrangements in advance. For children scheduled for individual therapy without parent present, payment should be made in advance or sent with child (services will not be provided otherwise). Accounts more than 30 days overdue will be subject to $20 late fee and 5% interest charge per week late. Accounts more than 60 days overdue will be sent to collection. For clients seeking 3rd party reimbursement, be aware that you are ultimately responsible for the payment of services rendered. In the event that your insurance carrier denies payment (including recoupment) or does not remit payment within 45 days, the client will be responsible for payment of all services rendered. I may at times provide discounts or fee waivers for families with extenuating circumstances; however, it is the client’s responsibility to ensure acceptance of such fee reductions will not adversely affect third-party payment obligation.
Termination of Services: In the event that you do not keep your financial obligations to KidSpeak, LLC and remain delinquent on your account for more than 60 days, services will be suspended until payment is received. Services may also be terminated if it is determined that continued participation will be a detriment to the child or their family.
POLICIES AND PROCEDURES (CONT.)
Health Insurance: I participate with some insurance companies, but not all. In the event that I do not accept your insurance, I will be happy to provide you with the necessary paperwork to assist you in seeking reimbursement for out-of network provider services. Please also be advised that many health insurance plans have limited coverage for speech-language pathology services. I recommend that you contact your insurance company to discuss the limits of your coverage. Any referrals that may be required are the sole responsiblity of the client/member to obtain prior to the first visit, if needed, for the particular plan (e.g. HMO, etc.).
Health Policy: Help and cooperation is required in order to maintain a healthy environment. A child must be temperature free for 24 hours before returning to therapy. If your child has vomiting and/or diarrhea, he/she should not return to therapy until 24 hours have passed since the last episode of the same. Children will not be seen if any of the following is present:
Audio/Video Recording Policy: At KidSpeak, we welcome the use of video/audio recording as a means of training parents and caregivers on important carryover techniques. However, the use of cameras, video, audio recording devices, or digital devices that have recording capability, such as cell phones, MP3 players, or PDAs, ipads, tablets and Smartphones can cause violations of privacy and breaches of confidentiality. In light of this, we do require a video consent by both KidSpeak and parents to be completed each time recording is initiated.
Lost/Damaged/Misplaced Materials: At times I will make tools or supplies available for use during the course of therapy. These materials are for LOAN ONLY unless otherwise agreed upon in writing. If materials/tools/books or similar are damaged, lost or misplaced, it is the responsibility of the client to replace the items OR remit equivalent payment so the items may be replaced by KidSpeak, LLC.
NOTICE OF PRIVACY POLICIES
This form describes the confidentiality of your medical records, how the information is used, your rights, and how you may obtain this information.
Our Legal Duties: State and Federal laws require that we keep your medical records private. Such laws require that we provide you with this notice informing you of our privacy of information policies, your rights, and our duties. KidSpeak, LLC is required to abide these policies until replaced or revised. KidSpeak, LLC have the right to revise our privacy policies for all medical records, including records kept before policy changes were made. Any changes in this notice will be made available upon request before changes take place. The contents of material disclosed to us in an evaluation, intake, or counseling session are covered by the law as private information. KidSpeak, LLC respect the privacy of the information that you provide us and we abide by ethical and legal requirements of confidentiality and privacy of records.
Use of Information: Information about you may be used by the personnel associated with KidSpeak, LLC for diagnosis, treatment planning, treatment, and continuity of care. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian or personal representative. It is the policy of KidSpeak, LLC not to release any information about a client without a signed release of information except in certain emergencies or exceptions in which client information can be disclosed to others without written consent. Some of these situations are noted below, and there may be other provisions provided by legal requirements.
Duty to Warn and Protect: When a client discloses intentions or a plan to harm another person or persons, the health care professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.
Public Safety: Health records may be released for the public interest and safety for public health activities, judicial and administrative proceedings, law enforcement purposes, serious threats to public safety, essential government functions, military, and when complying with worker’s compensation laws.
Abuse: If a client states or suggests that he or she is abusing a child or vulnerable adult, or has recently abused a child or vulnerable adult, or a child (or vulnerable adult) is in danger of abuse, the health care professional is required to report this information to the appropriate social service and/or legal authorities. If a client is the victim of abuse, neglect, violence, or a crime victim, and their safety appears to be at risk, we may share this information with law enforcement officials to help prevent future occurrences and capture the perpetrator.
NOTICE OF PRIVACY POLICIES (CONT.)
Prenatal Exposure to Controlled Substances: Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. In the Event of a Client’s DeathIn the event of a client’s death, the spouse or parents of a deceased client have a right to access their child or spouse’s records.
Professional Misconduct: Professional misconduct by a health care professional must be reported by other health care professionals. In cases in which a professional or legal disciplinary meeting is being held regarding the health care professional’s actions, related records may be released in order to substantiate disciplinary concerns.
Judicial or Administrative Proceedings: Health care professionals are required to release records of clients when a court order has been placed. In the event of a court order, only the minimally acceptable amount of information will be revealed. Additionally, if a client files a complaint or lawsuit against anyone affiliated with KidSpeak, LLC; relevant information regarding the client may be disclosed for the purpose of formulating an appropriate defense.
Minors/Guardianship: Parents or legal guardians of non-emancipated minor clients have the right to access the client’s records unless it is determined that access would have a detrimental effect on the therapeutic relationship, or on the client’s physical safety or psychological well-being.
Other Provisions: When payment for services is the responsibility of the client, or a person who has agreed to providingpayment, and payment has not been made in a timely manner, collection agencies may be utilized incollecting unpaid debts. The specific content of the services (e.g., diagnosis, treatment plan, progress notes, testing) is not disclosed. If a debt remains unpaid it may be reported to credit agencies, and the client’s credit report may state the amount owed, the time-frame, and the name of the clinic or collection source. Insurance companies, managed care, and other third-party payers are given information that they request regarding services to the client. Information that may be requested includes type of services, dates/times of services, diagnosis, treatment plan, description of impairment, progress of therapy, summaries or copies of the entire clinical record. Only the minimally acceptable amount of information will be released to accommodate such requests.Information about clients may be disclosed in consultations with other professionals in order to provide the best possible treatment. In such cases the name of the client, or any identifying information, is not disclosed. Clinical information about the client is discussed. Some progress notes and reports are dictated/typed within the practice or by outside sources specializing in (and held accountable for) such procedures. Communications with the client outside the clinic setting will only occur as authorized by the client. When it is necessary to contact the client via telephone, messages will not be left on voicemails (or with persons other than the client or the client’s legal guardian) unless KidSpeak, LLC has received written authorization to do so.
Complaints: If you have any complaints or questions regarding these procedures, please contact me. If you believe your privacy rights have been violated, complaints should be directed to KidSpeak, LLC. If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to: Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C. 20201. There will be no retaliation for filing a complaint with either KidSpeak, LLC or the Office of Civil Rights.
As a recipient of services at KidSpeak, LLC, we would like to inform you of your rights. Below is a description of each. If at any time you feel your rights have been violated, please contact KidSpeak, LLC. You have the right to:
This form must be completed before services can be initiated. If the client is under the age of 18 years, the form must be signed by all legal guardians.
Treatment Consent: I hereby attest that I have voluntarily applied for and entered into treatment, or give my consent for the minor or person under my legal guardianship, at KidSpeak, LLC. I understand that I may terminate these services at any time. Receipt of Policies and Procedures I hereby attest that I have received a copy of KidSpeak, LLC’s Policies and Procedures, including payment, cancellation and health policies, and have read, understand and consent to be bound by its content.
Receipt of Patient’s Rights: I hereby attest that I have received a copy of the Patient Rights notice, have read, and understand its content.
Photocopy Authorization: I permit a copy of this form as if it were original executed consent.