• New Patient Form

    Info@integrityspeechtherapy.com Maryland Phone: (301)-337-7893 Oakland Phone: 510-631-2753 Fax: (855)-754-8261
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  • Educational History

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  • Consent for Services

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  • Consent for Telehealth Consultation

  • I understand that my health care provider wishes me to engage in a telehealth consultation. My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.

  • Consent to Use the Telehealth By SimplePractice Service

  • BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

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  • AUTHORIZATION FOR RELEASE AND/OR REQUEST FOR INFORMATION

    I hereby request and authorize: Integrity Speech Therapy in verbal and/or written communication with and release records to engage in communications via email/mail regarding the information checked below concerning patient

    I understand that information concerning psychiatric, psychological, medical diagnosis, drug or alcohol abuse, economic status, and educational information will be released and/or communicated if indicated below. I further understand that this information might contain information regarding my family.

  • I hereby request and authorize: Integrity Speech Therapy in verbal and/or written communication with and release records to engage in communications via email/mail regarding the information checked below concerning patient , whose date of birth is   Pick a Date   

  • I understand that information concerning psychiatric, psycological, medical diagnisis, drug or alchohol abuse, economic status, and educational information will be released and/or communicated if indicated below. I further understand that this information might contain information regarding my family.

  • For the purpose of:

  • I acknowledge that all information I authorize to be released or requested will be held strictly confidential and cannot be released by the recipient without additional written consent. I understand this authorization will expire one (1) year after the date signed, or on,   Pick a Date   whichever is earlier. A copy of this authorization is valid in lieu of the original. I further understand that I may withdraw my consent in writing at any time.

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  • CONSENT FORMS

  • Consent to Treat In Facility

    In signing below, I give permission for Integrity Speech Therapy to provide speech and language therapy, in his/her Day Program facility.

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  • Consent to Share Therapy Goals with Facility

    In signing below, I give permission for Integrity Speech Therapy and therapist to discuss therapeutic techniques and therapy goals with staff. In doing this, the staff can reinforce therapy goals throughout the day.

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  • Consent to Video and/or Audio Tape

    In signing below, I give permission for Integrity Speech Therapy to video and/or audiotape for evaluation and therapeutic purposes as well as documentation/tracking progress and will not be shared with anyone else other than those authorized by parent/guardian.

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  • IN-HOME AGREEMENT

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  • Photo/Video Release Form

    In signing below, I give permission to Integrity Speech Therapy to have the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of my child, for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium. I hereby release Integrity Speech Therapy and the institutions' legal representatives for all claims and liability relating to said images or videos. Furthermore, I grant permission to use my statements and audio comments that were given during an interview or guest lecture, with or without my name, for the purpose of advertising and publicity without restriction. I waive my right to any compensation.

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  • Mode of Communication with Integrity Speech Therapy

  • If you have authorized Integrity Speech Therapy to communicate and correspond with you via email, you acknowledge that Integrity Speech Therapy may transmit personal and confidential information to you regarding your child's treatment by email over the Internet. Integrity Speech Therapy will use reasonable means to protect the security and confidentiality of e-mail information sent and received; however, Integrity Speech Therapy cannot guarantee the privacy and security of such information. It is your duty to protect your email account, password and computer against access by unauthorized people. Integrity Speech Therapy will not be liable in the event that you or anyone else inappropriately uses or accesses your email. You agree that should any information sent to you by Integrity Speech Therapy be intercepted or otherwise accessed or modified by an unauthorized third party, you shall fully release, discharge, and hold harmless Integrity Speech Therapy from any damages arising directly or indirectly from such interception or access. You may revoke your authorization for Integrity Speech Therapy to communicate with you by email at any time by written request.

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  • Attendance/Cancellation Policy

  •  Attendance and participation in therapy along with complete compliance with any associated home programs are essential for therapeutic success. While Integrity Speech Therapy understands that illnesses and emergencies occur, we respectfully request that you avoid frequent cancellations or "no shows". Please adhere to our following policy regarding providing our office with advance notification for any cancellations resulting from a conflicting appointment, vacation, obligations for work or family, or any other

    *All cancellations must be submitted 24 hours prior to your scheduled appointment**

     

  • COMMERCIAL INSURANCE ONLY

    **A fee of $50 may be assessed if the following occurs.**

    This fee will be billed directly to the client and not their health insurance company, as medical insurance does not provide coverage for missed sessions. 

    • If cancellations are made less than the required 24 hours. 
    • If the client fails to show up for a scheduled appointment(s)
  • If you are late for 5 scheduled appointments within a plan of care period (6 months), the office reserve the right to reduce services and/or discharge the client. Additionally, if you arrive late for appointment, the session will still end at the scheduled time or may be canceled.

  • If you fail to appear for an appointment (no show) without providing the appropriate advance for two or more appointments within a plan of care period (6 months), the office will reserve the right all pending appointments and to no longer offer services to you as a client.

  • I, , understand the attendance / cancellation policy and the risks of not adhering to it.

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  • Health Insurance Waiver Acknowledgement

  • While all patients sign the Financial Agreement as part of the initial registration documents, the Health Insurance Waiver Acknowledgment must be signed by the responsible party for the following patients:

    • Managed Care patients seeking treatment without a referral
    • Patients using the Point of Service options
    • Patients that have exhausted their benefit plan limits
    • Patients that wish to use Auto insurance claims instead of their health insurance
    • Self-Pay patients

    Agreement between Patient and Integrity Speech Therapy

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  • Acknowledgment That You Have Received Our HIPAA Privacy Notice

  • Integrity Speech Therapy is required by law to keep your health information and records safe. This information may include:

    • Notes from your doctor, teacher or another healthcare provider
    • Medical history
    • 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.

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  • HIPAA POLICY A NOTICE OF PRIVACY PRACTICES

  • This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. HIPPA provides penalties for covered entities that misuse personal health information. As required by HIPPA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. Treatment means providing, coordinating, or managing health care and related services, by one or more health care providers. An example of this would include a physical examination. Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collections activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment. Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review. We may create and distribute de-identified health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer: The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosure to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

    • The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
    • The right to inspect and copy your protected health information.
    • The right to amend your protected health information.
    • The right to obtain a paper copy of this notice from us upon request.

    This notice is effective as of 11/1/2019 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaints with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

    Please contact the following for more information: The U.S. Department of Health & Human Services Office of Civil Rights 200 Independence Avenue, S.W., Washington, D.C. 20201 Phone: (202) 619-0257 or Toll Free: 1-877-696-6775

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