Client Contract

Thank you for selecting Talk Play Learn Speech Therapy as your provider for speech therapy services. This contract identifies the expectations and duties of the speech-language pathologist, client, and/or client’s parties.

Notification of Legal and Privacy Policies

Speech Therapy services are provided at the office location at 6523 SE King Rd, Milwaukie OR 97222 by a licensed speech-language pathologist (SLP).

Evaluation reports, progress reports, therapy goals and therapy plans will be sent to outside sources for the purpose of continuity of care and normal billing practices (i.e- doctor's offices, insurance providers) in a secure manner, if applicable.

An Authorization for a Release of Information will be obtained to share private information with other outside sources or professionals as necessary during the course of treatment that fall outside the scope of normal business. 

Talk Play Learn Speech Therapy 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 test results 
• treatment notes
• insurance information

We are required by law to give you a copy of our privacy notice. This notice tells you how your health information may be used and shared. It also tells you how you can look at and comment on your information. This privacy notice is available on our website and at our office location upon request.

 

Authorization for Treatment

When providing speech language pathology services, health care laws require us to obtain authorization from the patient or parent/guardian to provide services. This authorization is your agreement to allow Talk Play Learn Speech Therapy and its employees to render care within our scope of practice.

I agree to allow Talk Play Learn Speech Therapy to provide speech-language pathology services for myself or my child/person in my care. 

TPL Speech is a multi-practitioner office. In order to provide best care to our clients, we may discuss case details, sessions may occasionally include additional practitioners, we may video-record sessions, or we may share chart notes and reports to collaborate on best treatment methods and options. Protected information is never shared outside of our organization and is used only to provide care.

An initial evaluation can be provided at the request of the client/client’s parents; however, we are not required to conduct our own independent evaluation to establish a treatment plan in order to bill for our services.

• Parents can provide their child’s school, hospital, and/or previous private practice evaluation report as a means of generating speech goals, if available.
• If the evaluation report is dated one or more years ago, the speech-language pathologist may recommend reevaluation to obtain an updated account of the client’s ability level.
• Annual re-evaluation may be needed to determine progress and future goals.
• An updated evaluation is needed to establish goals and provide therapy.

Speech Therapy services will be provided based on goals agreed upon by both parties in order to best serve your child. Goals can be established through one or more of the following means: administered evaluations/reports; outside evaluations/reports; observations; and parent requests.

It is required that an adult is present during your child’s therapy session. Adults are welcome to observe therapy sessions or to be active participants in therapy as is deemed most appropriate. Parent involvement in sessions and between sessions is crucial for the child’s progress, as children spend most of their time with their parents, not with their therapists.

Session Structure: 

• sessions are approximately 30 minutes in length.
• first 5 minutes are used to review homework and generally check in with family and child;
• work on goals directly, with family member(s) participating or observing;
• last 5 minutes used for clean-up/transition and to review skills/strategies the family should work on with the child until the next session. 
• If planned for, your therapist may also email you information for home programming.

Goals for speech therapy will be formed based on initial evaluation results, which include parent input.

As treatment begins, a Plan of Care (POC) will be provided to client/parent/guardian as applicable. A POC will include some information about current skills, as well as goals for therapy. 

Approximately every 3 months or after 10-12 sessions, a progress report will be provided with information about the child’s goals, progress toward those goals, and recommendations for next steps. At that time goals may be changed based on parent input and current progress.

Usual and Customary Rates
Our practice is committed to providing the best treatment for our clients and we charge what is usual and customary for our area and for our services. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.

Collections
You are expected to make payment on bills on time and in full. In the event that we are unable to collect any past due amount after a minimum of 3 attempts to collect, we may at our discretion refer the account to our collections agency. If we refer the account to a collections agency, you agree to pay the collections fee up to 25% of the total bill in addition to the account balance.

Insurance
TPL Speech accepts insurance. Your insurance policy is a contract between you and your insurance carrier. TPL Speech is not responsible for and cannot affect how your insurance carrier processes claims or what the patient portion of the bill is. You will be responsible for un-covered charges processed through your carrier that are not contractual write-offs. Please inquire about the insurance we accept as this list changes.

Please make all co-payments at the time of service and payable to Talk Play Learn
Speech Therapy. You may be asked to save a card on file so that you co-pay is automatically paid within a week of your session. If you elect to use your insurance you agree to grant us the right to bill your insurance and you authorize your insurance carrier to assign benefits to us.

Accepted Methods of payment: 

• Cash: Exact change required.
• Personal Check: Please make payable to Talk Play Learn Speech Therapy.
  • Returned check fee: $35.
• Credit/Debit Cards: MasterCard, Visa, Discover, American Express or your
  HSA/FSA card

Private Pay

Full payment is due to Talk Play Learn Speech Therapy at the time of service. Your
insurance policy is a contract between you and your insurance company. Please be
aware that some, and perhaps all, of the services provided by TPL Speech Therapy may be non-covered services and not considered reasonable, customary and/or medically necessary under your medical insurance plan. You may seek reimbursement for these services directly from your insurance company. If you are unsure about the process for filing a claim, we recommend that you call the customer service number on the back of your insurance ID card.

Speech-language services provided by Talk Play Learn Speech Therapy will likely be
considered out-of-network by your insurance company. Upon request, we will provide you with the information necessary to bill your insurance company, including diagnosis codes and treatment plans. This document is called a superbill and can be emailed to you.

We are not responsible for any charges your insurance company considers to be in excess of reasonable or customary fees as well as those considered medically unnecessary.

By the execution hereof, the undersigned acknowledges his/her/their responsibility to pay any amounts not paid or reimbursed by insurance. The undersigned specifically accepts all financial responsibility for all services provided to the herein named client by Talk Play Learn Speech Therapy and understands that regardless of what the insurance company agrees to pay, the undersigned will be responsible for the full balance. Said balance will be paid in advance of and without regard to the status of processing by the insurance carrier.

Other Billed services: TPL Speech offers additional services, including screenings, evaluation, and attending parent-teacher conferences or other team meetings for your child, as per therapist availability and discretion. These services will be billed in addition to the therapy session charges at the hourly rate or as stated in Fee Schedule below. Team meeting attendance is not typically covered by insurance. 

Fee Schedule

Our practice is committed to providing the best treatment for our clients and we charge what is usual and customary for our area and for our services.

Evaluation

Stuttering/Fluency Evaluation (92521) - $250.00
Includes consultation with parent and file review, 30-45 minutes of direct contact,
approximately 1-1.5 hours of analysis and interpretation and includes a thorough report.

Articulation/Phonology Evaluation (92522) - $250.00
Includes consultation with parent and file review, 30-45 minutes of direct contact,
approximately 1-1.5 hours of analysis and interpretation and includes a thorough report.

Comprehensive Speech-Language Evaluation (92523) - $350.00
Includes consultation with parent and file review, 1-2 hours of direct contact, possibly over 2 sessions, followed by approximately 1-2 hours of analysis and interpretation and includes a thorough report.

Therapy

Individual Speech Therapy Session (92507) - 30 min - $110.00
Inclusive of preparation time, resources/materials made for your child’s therapy, record keeping, home programming, quarterly progress reports, and consultation with other professionals to coordinate therapy.

Other Services
(Not billable to insurance. Billed in 15 minute increments.)

Progress/Team Meetings $110/hr
Meetings outside of treatment time at the discretion of the Talk Play Learn Speech Therapy therapist.

Travel Time for Progress/Team Meetings $80/hr
Travel time to meeting to and from the office location.

Discounts

Time of Service Discount: We offer a 10% prompt pay/time of service discount on all services. This discount is only available for payments received on or before the date of service. 

 

Talk Play Learn Speech Therapy wants to provide the best possible services to all clients. We will do our best to schedule appointments that meet your needs. Regular attendance is important to you/your child’s success. It is also important to mutually respect one another’s time. We ask that you follow the attendance policies outlined below:

• Cancellations/Missed appointments: 
  • If you will not be able to attend your scheduled appointment, please text, or call your therapist, or the office,  24 hours in advance when possible. When this is not possible, please ensure to contact your therapist, or the office, by 9am on the day of your appointment . We will schedule a make-up when possible at a time convenient to both client and provider.
  • If you do not give adequate notice and miss your session, that is considered a "no-show." A make-up may not be available, and you will be charged a $40 late cancellation fee . This fee will not be billable to insurance and you will be responsible for payment.
  • We understand that sometimes emergencies happen. All clients will be allowed 1 (one) free cancellation in a 3-month treatment period.
  • To receive therapy at TPLSpeech, we require a minimum of 75% attendance or better. Inconsistency of treatment does not allow for progress necessary to substantiate treatment. If attendance drops below 75%, the parent will be given notice that attendance needs to improve. If difficulty with attendance continues, we may choose to discharge your child from care. 
  • Two (2) no-shows in a row tell us that you are not able to commit to therapy at this time, and will also mean that your child will be discharged from care. 
  • If you need to take a break, your appointment slot will be held for you for up to 3 weeks. After 3 weeks, the slot will be released and you will need to re-establish at a different time or be placed on our wait list.
• Late for Appointment
  • If you/your child arrive late to an appointment, the session will end at the regular time. Please call or text your therapist if you are running late. If you are 15 or more minutes late for your appointment, we reserve the right to cancel the appointment and consider it a missed appointment (see policy for missed appointments above).
• Clinical Cancellations
  
  • If your provider us unable to attend your appointment, you will be contacted as soon as possible. Please keep us updated with your most current contact information. Every effort will be made to reschedule your appointment in a timely manner.
• Inclement Weather
  • During the school year, we generally follow along with North Clackamas School District recommendations. However, please check in with us by phone (call or text) regarding your specific appointment. For example, even if the roads are icy in the morning, if the forecast is for clear roads in the afternoon, your appointment may not need to be cancelled. If the decision will be made to close the office for the day, you will receive a
    cancellation text that morning. When possible, a teletherapy appointment can be offered if commuting to the office is not considered safe.
• Discontunation of Services
  • Please provide two weeks (14 days) advance notice if you choose to discontinue services or you wish to put services on hold so that we may plan accordingly.
  • If attendance drop below 75% or two no-shows occur in a row, we will check in with you about any changes that may need to happen to help continue services, or we may inform you that we are discontinuing services. 
• Therapist Vacation
  • Throughout the year providers may take leave/vacation and you will be given advance notice. If coverage is not available during this time, then no sessions will be scheduled, no make-ups will be offered, and you will not be charged any fees.

Please contact your therapist first if you have any questions or need to make changes with your appointment. You may also contact the office via call or text at 503-852-1375 if you have any questions or concerns or need to make changes to your appointment. 

Please leave a message if you would like a call back. The phone will be answered during office hours, or you will receive a call the next day.

Texts are preferred when you just have one quick question or need to make a change to your appointment time. Texts will be returned during office hours.

With your consent, you will also receive communication via text and secure email.

Your therapist's email is a HIPAA compliant secure email account and anything you email will be protected. Email sent to you may be encrypted and password protected if it includes protected health information. 

I have read, understand, and agree to the policies outlined above. This is the agreement in its entirety, and no promises outside of the agreement made on or before the effective date will be binding upon the parties. My signature indicates that I consent to all rules policies and fees of Talk Play Learn Speech Therapy.