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.

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.

 

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, sessions may include additional practitioners, graduate students and/or clinical fellows. We may discuss case details, video-record sessions, or we may share chart notes and reports to collaborate on best treatment methods and options within our organization. Protected information will only be shared outside of our organization to maintain continuity of care with a referring provider, for example, sending evaluation and progress reports to the referring PCP. If you would like us to communicate with other providers, please let us know, as a release of information consent will be necessary. 

The American Speech-Language-Hearing Association (ASHA) defines telepractice as "the application of telecommunications technology to delivery of speech language pathology and audiology professional services at a distance by linking clinician to client, or clinician to clinician, for assessment, intervention, and/or consultation." This service delivery model is supported by the Oregon State Hearing & Speech licensing board and the American Speech-Language-Hearing Association (ASHA).

Telepractice is viewed as a mode of delivery of health care services, not a separate form of practice. There are no legal prohibitions to using technology in the practice of speech language pathology and audiology, as long as the practice is done by an Oregon State licensed practitioner. All of our clinicians are state licensed and ASHA certified. The standard of care is the same whether the patient is seen in-person or through telehealth (telepractice).

TPL Speech offers services through the live interactive, HIPAA compliant, video conferencing platform Zoom. Once the clinician is online, the clinician and the child will then be able to see and hear each other in real time. The clinician is able to perform diagnostic assessments and provide treatment via telepractice.

Talk Play Learn offers the option of conducting sessions via telepractice, when it is appropriate for the child and agreed upon with the family.

Standard of care is the same whether the child is seen in-person or through telepractice and family will be notified immediately if it is determine that this delivery model is not appropriate.

 

Requirements for teletherapy

• Consistent, and reliable internet connection.
• Tablet or computer that has a microphone and camera and is charged.
• Quiet space in the home with minimal distractions where the child and the parent can sit comfortably and care information can be discussed securely.
• Good lighting, with a wall behind the child (or a window with curtains drawn)
• Adult facilitator present or nearby throughout the entire session to facilitate.
• Toys/Materials needed for session if planned with therapist in advance.
• Snack and a drink available to the child during the session.

The family has the right to withdraw consent to participate in telepractice at any time without it affecting their right to future care, though in person services may not be available at that time.

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 more than 9-12 months ago, the speech-language pathologist may recommend reevaluation to obtain the child's current level of ability.
• Annual re-evaluation may be needed to determine progress and future goals as well as insurance use requirements.
• 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 3-4 months or after 12-15 sessions, a progress report will be provided with information about the child’s goals, progress toward those goals, and recommendations for next steps.

No pets or emoitonal support animals are allowed. Service animals as defined by the ADA are always permitted. 

Our clinic is a low-fragrance environment. Please refrain from wearing strong scents (colognes, body sprays), or wearing clothing that is fragrant (ex: smoke from marijuana or cigarettes, barn clothes, etc). We aim to provide an environment that is comfortable to all.

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 will be asked to save a card on file so that you co-pay is automatically paid the day of your visit, or 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: 

• 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 and You will be asked to save a card on file. 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 consulting with other specialists, and attending parent-teacher conferences or other team meetings for your child, via video conferencing, 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 and are 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) - $245.00
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) - $205.00
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) - $360.00
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 - $120.00
Inclusive of preparation time, resources/materials made for your child’s therapy, record keeping, home programming, quarterly progress reports, and some consultation with other professionals to coordinate therapy.

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

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

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 in full received on or before the date of service. 

 

Under the law, health care providers need to give patients who don't have insurance or are self-pay an estimate of their bill for health care items and services before those items or services are provided.

The above Fee Schedule is a detailed list of expected charges for the listed services. Expected costs will be reviewed again either verbally or by email before your scheduled appointment.

You may need more than one treatment. We are unable to anticipate the length of care as all people progress at different rates. A diagnosis will not be available until treatment begins.

This estimate is accurate within +/- $400 of the actual cost of the care for one visit. The provider may recommend additional items or services as part of the treatment that are not reflected in the estimate. These would need to be scheduled separately and you have the option to decline.

The information provided in the Good Faith Estimate is only an estimate, as actual items, services, or charges may differ. The client has the right to engage in a dispute resolution process if the actual costs of services significantly exceed those listed in the Good Faith Estimate. The Good Faith Estimate does not obligate or require the client to obtain any of the listed services from the provider. The estimated costs are valid for 12 months from the date of the Good Faith Estimate.

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. Individuals insured through OHP are not subject to cancellation fees. 

• 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.
  • An attendance contract will be offered
  • If difficulty with attendance continues, your child will be discharged 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 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.

• Whenever 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 discharging your child from 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.