New Patient Intake

Welcome!
Thank You for choosing Speech Language Associates

In order to serve you in the best possible manner we will need to collect some information. This inludes:
1. Patient Information
2. Case History
3. Responsible Party Information
4. Insurance Information
5. CC Information
6. Cosent and Acknowledgement Forms
You will want to have the above information handy when filling out this document. We are required by law to have many of these forms on file. In an effort to streamline this process we have prefilled as many of the fields as possible.

The following document is broken down into sections. Just click on the section arrow to view the questions. You can collapse the section once complete to make the document more readable.

If you have any questions regarding the forms please email billing@speechlanguageassociates.com.

Thank you again,

Kristy and Rachel
This patient is a *

Child Adult

Patient Intake Forms

Click on each selection below to enter information
Name of Person Completing the Forms *

First Name Last Name
Relationship to Patient

Patient Information
Patient Name *

First Name Last Name
Birthday *

Month Day Year
Date
Primary Doctor *
Name and Address of Physicians Practice *

Case History - Child
Mother's Name
Father's Name
Names of Siblings with ages and others living in household
What type of speech disorders or delays is the patient experiencing?   DisordersWhat other languages are spoken in the home?  Languages
What is the patients primary language?   Primary
Secondary language:   Secondary
Has the patient experienced frequent ear infections, how often:   Infections
Has the patient had previous otological care:   Otological
Has the patient had any surgeries? What kind?   Surgeries
What was the date of their last hearing screening:   Screening Date
What was the birth weight?
Was this a premature birth?
Were developmental milestones reached within normal timeframes?
What was the patients age when the first word was spoken?
Were there any issues with Mother's health, pregnancy or complications during delivery?
Please outline when you first became concerned about their speech, any family history of developmental or speech delays.

Case History
Date of Last Hearing Screening

Month Day Year
Date
What concerns regarding the patients hearing
Surgical History
Does the Patient have any previous medical or in the case of a child ,school classifications? Please list diagnosis and date of diagnosis.
Please list all medications and how the medication has impacted behavior
Please provide the dates, provider and results of any previous speech language evaluations. ( it would be helpful if you also attached a copy of these results
Copy of any previous Speech Language Results

Cancel of

Financial Responsibility Information
Please provide information on who is financially responsible for the provided services.
Name *

First Name Last Name
Phone Number
Please enter a valid phone number.
Mobile Number
Please enter a valid phone number.
Email
example@example.com
Preferred Communication Method

Mobile Work Email Text
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Insurance Information
Insurance Company
Policy Holder
Relationship to Patient
Group #
ID
Policy Holders Date of Birth

Month Day Year
Date
Patients ID # (if available)
Copy of Insurance Card - Front

Cancel of
Copy of Insurance Card - Back

Cancel of

Payment Policy Agreement
As a courtesy, Speech Language Associates, verifies the benefits with your insurance company. A quote of benefits is not a guarantee of benefits or payment. The claim will process according to your plan, if your claim processes differently from the benefits we were quoted, the insurance company will side with the plan and will not honor the benefit quote we received.

It is the policy of Speech Language Associates, that payment is due at the time of service unless other financial arrangements are made in advance. We require all patients to pay their deductible, copay and/or coinsurance payment and any outstanding balance at the end of each visit. If there is a credit, you will be provided a refund.

If the patient is covered by one of our contracted health insurance carriers and has Speech/Language benefits, we will be happy to bill your insurance. Accepting your insurance does not place all financial responsibilities onto this practice, and you are responsible for any unpaid balances by your plan. As a rule, we will bill your credit card on file for the unpaid balance 10 days after receiving the Explaination of Benefits from your carrier. We do not sent automated monthly statements to request payment through mail.

Although we are contracted with several insurance carriers, our services may not be covered by your particular insurance plan. Being referred to our clinic by another physician does not necessarily guarantee that your insurance will cover our services. Please remember that you are 100 percent responsible for all charges incurred: your physician's referral and our verification of your insurance benefits are not a guarantee of payment.

If we do not participate with your insurance carrier, you will be responsible for Speech Language Associates fees at the time of service. You may request a receipt of services to submit directly to your insurance carrier by emailing billing@speechlanguageassociates.com. Speech Language Associates will provide additional information regarding services rendered upon request should your insurance carrier request more information beyond the receipt for services. It is your responsibility to contact their insurance carrier to determine the required documentation for filing insurance claims.

Failure to make any payment will result in the patient’s services being suspended until payment is received and your account is paid in full. Late fees of 1.5% per month will be charged on balances that are still unpaid starting 30 days after the first statement. There is a fee of $35 for returned checks. Delinquent accounts may be turned over to a collection agency at which time you agree to be responsible for any collections charge and all associated legal fees in addition to the amount owed.

You must notify Speech Language Associates of any change in insurance coverage or attending physician.
CANCELLATION & NO-SHOW POLICY

We strive to provide excellent care to our patients. In order to be consistent with this, we have a Patient No-Show and Cancellation Policy that we expect patients to adhere to. When an appointment is scheduled, that time has been reserved for you and when it is missed or cancelled on short notice, that time cannot be used to see another patient.

Cancellations and No Shows

You may cancel your appointment any time before 3 PM the day prior to the appointment with no consequence. We will reschedule the appointment for you and leave the time open for another patient to be seen. If you miss your appointment or cancel any time after 3 PM the day before, Speech Language Associates reserves the right to bill you the rate of the normal visit for each no-show and late cancellation. This fee is the patient’s/responsible parties’ responsibility and is not billable to insurance.

Additionally, if a patient is more than ten (10) minutes late to his/her appointment, we reserve the right to cancel the appointment and the cancellation fee will apply. If the patient misses 3 or more appointments within a 6-week period, Speech Language Associates reserves the right to place your patient’s services on hold until scheduling conflicts are resolved. A consistent schedule is essential to patient progress in speech-language therapy.

We do realize that on rare occasion emergencies may arise and we will address these situations with you at that time. We thank you for working with us to ensure that services are provided to all our patients in the best possible way.

Illness

If the patient has a fever, a persistent cough, or a runny nose, please call and cancel your appointment. Speech language therapy requires the therapist be in close proximity to a patient’s face, putting them at a higher level of risk for contracting the illness and/or spreading it to other patients. As a general rule of thumb if the patient has been on an antibiotic for 24 hours and does not have a fever, is not coughing frequently, and does not have a runny nose, he/she is probably not contagious. We appreciate your understanding and will be happy to reschedule your appointment.

We do realize that on rare occasions sudden illnesses may arise and we will address these situations with you at that time. We thank you for working with us to ensure that services are provided to all our patients in the best possible way.

Inclement Weather

During times of inclement weather our primary goal is to keep our therapists and patients safe. To that end, Speech Language Associates reserves the right to cancel or reschedule appointments in the event of inclement weather. We follow the same inclement weather policy as the facility where the patient is being seen. If the facility closes at noon, we will automatically cancel all appointments after noon. If you are a private patient please contact your therapist during inclement weather. If a patient keeps the same appointment time each week, it is understood that they will be seen at the same time the following week.

AGREEMENT TO PAYMENT and CANCELLATION POLICIES

I have read and accept the above policies including payments, issed appointments, illness, and inclement weather.
Signature *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Date

Credit Card Authorization
CREDIT CARD AUTHORIZATION

i have read and agreed to the Payment and Cancellation policies of Speech Language Asscocitates. The undersigned hereby authorizes Speech Language Associates, LLC to charge the below-referenced credit card for services rendered and any related expenses.

In addition, I understand my credit card will be charged in the event that:
1. I do not pay my outstanding balance in full on the date of the visit.
2. There is a balance due after insurance benefits have been received.
3. Proper cancellation procedures are not followed as noted in the Cancellation and No Show Policy.
4. A check is returned for insufficient funds (fee of $35.00)
5. At discharge, if an account balance remains, your credit card will be charged for unpaid services to discharge date.
Credit Card Type *

Visa Mastercard Discover American Express
Name as it appears on Credit Card *
Credit Card Number   *
Expiration Date   *
Security Code   *
Billing Address on Credit Card *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I understand and agree it is my responsibility to inform Speech Language Associates, LLC of any changes to my credit card information including address, zip code, updated expiration dates, account numbers and security codes.

BY SIGNING BELOW, I AUTHORIZE SPEECH LANGUAGE ASSOCIATES TO CHARGE THE CREDIT CARD INDICATED IN THIS AUTHROIZATION FOR UNPAID BALANCES ACCORDING TO THE TERMS OUTLINED ABOVE. I CERTIFY THAT I AM AN AUTHORIZED USER OF THIS CREDIT CARD AND WILL NOT DISPUTE THE PAYMENT WITH MY CREDIT CARD COMPANY; SO LONG AS THE TRANSACTIONS CORRESPOND WITH THE TERMS INDICATED IN THIS FORM AND/OR SPEECH LANGUAGE ASSOCIATES PAYMENT, CANCELLATION AND NO-SHOW POLICIES.
Signature *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Date

Communication Terms
Regarding the individual named above, I give permission for the therapist/Speech Language Associates to...
1. Communicate with me regarding therapy sessions (including progress, attendance, scheduling, etc.) via text, email and voicemail.
2. Communicate with me regarding therapy sessions (including progress, attendance, scheduling, etc.) via written note home at daycare/preschool/school. I understand that these notes will be left in my child’s backpack, cubby, folder, or wherever directed by my child’s teacher or caregiver.
3. Communicate with teachers and caregivers at my child’s school/daycare regarding therapy evaluation results/sessions in order to help carry-over skills learned in speech sessions.
4. Communicate with me via email regarding therapy. Some emails may include PDF attachments and Word documents which may or may not be password protected.
I understand that...
1. If I want my child’s therapist to communicate with anyone other than the parent/guardian of the child indicated on initial paperwork, I will sign and authorize consent to do so. I will request Speech Language Associates to do so in writing.
2. If a divorce or separation situation exists, a custody agreement and separation agreement will need to be shared with Speech Language Associates and my child’s therapist. I will share custody agreements with my therapist/Speech Language Associates so that my therapist only shares information with legal guardians of my child.
3. My child’s invoice for speech services will be emailed or mailed to me. Information containing diagnosis codes, procedure codes, dates of service, cost of service and insurance plan information will be included on these invoices.
4. If my child is seen in a daycare/preschool setting, my child will be seen where the teachers/daycare/preschool director instructs therapy to occur. This could mean that therapy may occur in a public place, such as a hallway or resource room.
5. My child’s pediatrician will be sent orders for signature, as well as plans of care and progress notes.
I accept the above communication terms,
Signature *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Date

Permission to Treat and Terms of Service
Name of Patient *
PERMISSION TO SCREEN, EVALUATE AND/OR PROVIDE THERAPY

Speech-language evaluations consist of standardized testing, informal and formal observations, and clinical judgment. Treatment is based upon the findings of the evaluation and the recommendations of the responsible speech-language pathologist.

I, the parent or guardian, authorize Speech Language Associates, to screen, evaluate and/or provide the necessary speech and/or language treatment/therapy/services to the above named individual.
Signature *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Date
You will be contacted regarding the results of the screening. A complete evaluation and/or subsequent treatment will only be administered after a speeech therapist has spoken with you about the results of the screening and fees/insurance benefits. You will be asked whether you or the patient want to receive a comprehensive evaluation and if an evaluation is agreed upon, a state-licensed and certified speech-language pathologist will administer the evaluation (including standardized evaluation tests, language samples, caregiver interviews, etc.). Your therapist will provide subsequent treatment, if needed, to the aforementioned patient. Results of the evaluation will determine a treatment/therapy course that will include the recommendations of the speech-language therapist with input from the parent in the case of a child.

Consent or Release of Information
Individuals Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
CONSENT FOR RELEASE OF INFORMATION

I, or the Parent or Guardian of the aboved name individual, hereby grant Speech Language Associates permission to communicate with the following persons or agencies:
Physician
Email
example@example.com
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insurance Company
Email
example@example.com
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
If you would like us to communicate with any other professional/person regarding the patients communication skills, i.e., physical therapist, occupational therapist, teacher, etc, please list in the box below
Name
Role
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Speech Language Associates may discuss and release to the aforementioned person or agency information including but not limited to: evaluation reports, treatment plans, progress notes and therapy documentation, previous medical history, as well as necessary verbal communication pertaining to the Patient. This information will be used for diagnostic and treatment planning purposes only. It is my understanding that this information will not be shared with any other entity without my prior knowledge.
Signature *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Date

PATIENT NOTIFICATION OF PRIVACY POLICIES (HIPAA AUTHORIZATION)
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT YOUR PRIVACY RIGHTS

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Speech Language Associates is dedicated to ensuring the privacy of your child’s speech and/or language evaluation findings and course of therapy treatment. In serving our patients, we create records regarding treatment and services that are provided in order to have accurate information and ensure the appropriateness and efficiency of treatment services. Federal law requires us to strictly protect any personally identifying information on your child. This notice discloses our policies regarding the storage, use, and sharing of confidential patient information. PLEASE REVIEW THIS NOTICE CAREFULLY.

Speech Language Associates, LLC is required by law to keep your health information safe. This information may include:
- Notes from your doctor, teacher, or other health care provider
- Your medical history
- Your assessment resultsTreatment notes
- Insurance information
A government rule requires that you get a copy of this privacy notice. This rule is called the Health Insurance Portability and Accountability Act, or HIPPA for short. We will ask you to sign a paper acknowledging that you have been given this notice.

How Your Health Information May Be Used or Shared

We may use your health information without your permission for the following reasons:

Treatment: We may share your information with doctors or other health care providers who care for you. For example, if your doctor orders speech therapy, we will share the results of our treatment with that doctor.
Payment: We may use and share information about the treatment you receive with your insurance company or other payer to receive payment for therapy services. This may include sharing important medical information. We may share information to:
- Get the insurance company’s permission to start treatment
- Get permission for more treatment
- Get paid for the treatment you receive
Health Care Operations: We may use and share your health information to run the clinic and make sure all patients receive good care. For example, we may use your health information to:
- See how well our services are working
- See how well our staff is doing
- See how we compare to other clinics and private practices
- Make our services better
- Help others study health care services
Your health information may also be used or shared without your permission for:
- Abuse and Neglect: We may share your health information with government agencies when there is evidence of abuse, neglect, or domestic violence.
- Appointment Reminders : We will use your information to remind you of upcoming appointments. Reminders may be sent in the mail, by email, or by phone call or voicemail message. If you do not wish to get reminders, please tell your speech-language pathologist.
- As Required by Law: We will share your information when we are told to by federal, state or local law. We will also share information if we are asked by the police or courts.
- Government Functions: Your information may be shared for national security or military purposes. If you are a veteran, your information may be shared with the Office of Veteran’s Affairs.
- Information About a Person Who Has Died: We may share information with the coroner, medical examiner, or a funeral director, as needed.
- Health-Related Benefits and Services: We may use your information to let you know of other services that might be of interest to you.
- Public Health Risks: We may report information to public health agencies as required by law. This may be done to help prevent disease, injury, or disability. It may also be done to report medical device safety issues to the Food and Drug Administration and to report diseases and infections.
- Regulatory Oversight: We may use or share your information to report to agencies overseeing health care. This may include sharing information for audits, licensure and inspections.
- Threats to Health and Safety: Your health information may be shared if it is believed that it will prevent a threat to your health and safety or the health and safety of others.
- Worker’s Compensation: We will share your information with Worker’s Compensation if your case is being considered as a work-related injury.
When Your Permission is Needed to Use or Share Your Health Information

You must give us your permission to use or share your health information for any situation that is not listed on this notice. You will be asked to sign a form, called an authorization, to allow us to share your information. You are allowed to take back this authorization, called revoking authorization, at any time. We will not be able to get the information back that we shared with your permission.

Your Privacy Rights

You have the right to:
- Ask us not to share your information: You can ask us not to use or share your information for treatment, payment, or health care operations. You can also ask us not to share information with people involved in your care, like family members or friends. You must ask for limits in writing. We must share information when required by law. We do not have to agree to what you ask.
- Ask us to contact you privately: You can ask us to only contact you in a certain way or at a certain place. For example, you may want us to call you but not email. Or you may want us to call you at work and not at home. You must ask in writing.
- Look at and copy your health information: You have the right to see your health information and get a copy of that information at any time. You have the right to see treatment, medical and billing information. You may not be able to see or copy information put together for a court case, certain lab results, and copyrighted materials, such as test protocols.
- Ask for changes to your health information: You can ask us to change information that you think is wrong. You can also ask that we add information that is missing. You must ask us in writing and give us a reason for the change. We do not have to make the change.
- Get a report of how and when your information was used or shared: You can ask us to tell you when your information was shared and who we shared it with. There are some rules about this:
  - You need to ask us in writing.
  - You must tell us the dates you are asking about and if you want a paper or electronic copy.
  - You may get information going back six (6) years. This is the date when the government privacy rules took effect.
- Get a paper copy of this privacy notice: You can get a paper copy of this notice at any time.
- File complaints: You can file a complaint with us or with the government if you think that
  - Your information was used or shared in a way that is not allowed
  - You were not allowed to look at or copy your information
  - Any of your rights were denied
Who is Covered by This Notice

The people that must follow the rules of this notice are:
- All speech-language pathologists at Speech Language Associates, LLC.
- Anyone who is allowed to add health information to your file, including students and other staff
- Any volunteers who may help you while you are at this clinic/private practice
Changes to the Information in This Notice

WE may change this notice at any time. Changes may apply to information we already have in your file and any new information. Copies of the new notice will be available from our staff. The notice will have a date on the front page to tell you when it went into effect.

Complaints

You may file a complaint if you think we did something wrong with your information. You can complain to your regional office of the United States Office of Civil Rights. All complaints must be in writing. You will not get in trouble for filing a complaint.

Contacts

If you have any other questions about this notice or your privacy rights, please ask your speech-language pathologist.

I HAVE READ AND UNDERSTAND THE PRIVACY POLICIES DISCLOSED IN THIS NOTICE.
Signature *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Date

Privacy Notice Acknowledgement
Acknowledgement That You Received Your Privacy Notice

Speech Language Associates, LLC is required by law to keep your health information safe. This information may include:
- Notes from your doctor
- Your medical history
- Your test results
- Treatment notes
- Insurance information
We are required by law to give you a copy of your privacy notice. Please retain a copy of this privacy notice for your records. This notice tells you how your health information may be used or shared. It also tells you how you can look at and comment on your information.

By signing this page, you are saying that you have been given a copy of our privacy notice.
Signature *

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Name *

First Name Last Name
Date *

Month Day Year
Date
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Patient Intake Forms