Please provide information on who is financially responsible for the provided services.

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 time of service.  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 send 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 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 info@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.

In order to avoid incurring a cancellation or no show fee, you must contact our office at 856-492-1355 at least 24 hours prior to the scheduled appointment. 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 with less than 24 hours notice, Speech Language Associates reserves the right to bill you the cancellation/no show fee of $45. 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 our office will reach out to you to inform you of cancellation and/or the option to switch to teletherapy.   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. 

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.

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.

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,

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

You will be contacted regarding the results of the screening. A complete evaluation and/or subsequent treatment will only be administered after a speech 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.). A 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.

The speech therapist who performs the evaluation may or may not be the treating therapist. After the evaluation is completed, a report will be written up and shared with the patient and/or guardians. Our office will reach out to schedule any and all recommendations. 

Should a patient be recommended to receive continuous services, the office will schedule the patient based on office/therapist availability and patient availability. Due to scheduling, treatment plans, treatment changes, etc., there will be times that the patient will be scheduled with a different therapist than usual in order to maintain continuity of care. Please understand that a patient's therapist may change altogether from time to time and that all of Speech Language Associates' therapists are highly qualified and capable of delivering a high level of patient care. 

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:

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

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. 

You will be contacted regarding the results of the screening. A complete evaluation and/or subsequent treatment will only be administered after a speech 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.). A 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.

The speech therapist who performs the evaluation may or may not be the treating therapist. After the evaluation is completed, a report will be written up and shared with the patient and/or guardians. Our office will reach out to schedule any and all recommendations. 

Should a patient be recommended to receive continuous services, the office will schedule the patient based on office/therapist availability and patient availability. Due to scheduling, treatment plans, treatment changes, etc., there will be times that the patient will be scheduled with a different therapist than usual in order to maintain continuity of care. Please understand that a patient's therapist may change altogether from time to time and that all of Speech Language Associates' therapists are highly qualified and capable of delivering a high level of patient care. 

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.

Photo/Video Consent

Speech Language Associates, LLC asks that we use your's or your child's photos/videos for our website, training purposes, social media, literature, and our clinic spaces. 

If you choose to allow Speech Language Associates to use yours or your child's photos/videos, please sign below:

By signing this page, you are saying that you grant Speech Language Associates photo/video consent.

Speech Language Associates has established policies to ensure our clients have both a fun and safe experience while participating in therapy using our sensory gym. Please review the following policies. If you have any questions regarding our policies and procedures, please contact our office manager, by email or phone at admin@speechlanguageassociates.com or 856-492-1355.

• No food, drink or gum is allowed in the sensory gym. 
• No shoes on the mats, with the exception of shoes needed to position orthotics. 
  Siblings are not allowed on any equipment if present during evaluations or treatment. 
• All children and families must be accompanied by a therapist when in the gym. 
• Changing table is located in front lobby restroom for all diaper changes. 
• Parents are welcome to observe their child in the sensory gym; however, we ask that they remain seated in the chairs located in the gym.
• Use of the equipment and mats are reserved for the treating child and for the therapist only. 
   

Sensory Gym Release Waiver and Assumption of Risk 

I do hereby give my consent for my child to participate in the sensory gym at Speech Language Associates, LLC. I am fully aware that engagement in activities in the sensory gym presents a risk of injury during treatment and evaluations. I am fully aware of and appreciate the risk and damages that might occur as a result of my child's participation in or attendance at SLA. Nonetheless, I, on my own behalf of my child and our heirs, administrators and executors, do hereby release, indemnify and agree to hold harmless SLA and all persons or entities associated with SLA. from any responsibility or liability for any and all claims, demands, damages, costs, causes of actions and expenses (including, without limitation, reasonable attorneys' fees) arising out of or resulting from my child's participation in or involved with any therapy/evaluations, including without limitation, any personal injury, disability or property damages incurred or sustained by me or my child during or as a result of treatments/ evaluations conducted by SLA. I understand that the participant’s family medical insurance policy must cover any medical costs incurred in case of an accident. I do hereby verify that I fully understand and accept the preceding conditions for permitting my child to participate in therapy/evaluations at SLA.