New Patient Form

Do you need help filling out this form?

yes no

Name

Date

Date of Birth

Date

Social Security #

Address

City

State

Zip Code

Home phone

Work phone

Cell phone

E mail

example@example.com

Emergency Contact name

Phone

Caregiver/Spouse/Significant Other

Insurance Primary Member ID

Group #

Insurance Secondary Member ID

Group #

Please take a photo of the FRONT of your insurance card.

Please take a photo of the BACK of your insurance card.

What is the nature of your communication problem?

Have you received speech/language therapy in the past?

Yes No

If yes, Where?

For what reason?

Brief description of problem:

Present Employment

Address

Phone Number

Please enter a valid phone number.

School

Highest Grade Attended

Do you currently or have you ever experienced any pain associated with this problem:

yes no

If "yes' please describe:

Was this onset gradual or sudden? Describe:

Were there any special circumstances surrounding this onset? If yes, describe:

Is your general health:

Excellent Average Poor

If 'Poor' please explain:

Have you experienced any serious physical illness?

yes no

If yes, please explain:

Have you ever undergone an operation?

yes no

If yes, please explain:

Have you ever been hospitalized?

yes no

If yes, please explain:

Please list any medical problems you have experienced

Please list all of the medications you are currently taking

Name of Person Completing Form

First Name Last Name

Date

Patient Signature

Clear

Date

I authorize Integrity Speech Therapy to render appropriate evaluation and therapy services to the client named below in accordance with state and federal laws. I understand that care will be provided by a qualified, licensed, and trained health professional. I recognize, agree and understand that I have the right to refuse treatment or terminate services at any time by Integrity Speech Therapy in writing. In addition, Integrity Speech Therapy may terminate services by notifying me in writing. I do not give my consent or am withdrawing my consent regarding Integrity Speech Therapy rendering evaluation and/or therapy services to the client named below.

Print Name of Client

Date

Client Date of Birth

Date

Signature of Client or Legal Representative

Clear

Patient Clinic Name

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.

Please check:

I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from the location of my choosing. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

Telehealth by SimplePractice is the technology service we will use to conduct telehealth video conferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:

Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911. Though my provider and I may be indirect, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services. The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care. I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service - or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

By signing this form, I certify:

That I have read or had this form read and/or had this form explained to me. That I fully understand its contents including the risks and benefits of the procedure(s). That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

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

PATIENT/GUARDIAN

DATE

Date

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 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.

(Name of Person, Job Title and/or School/Agency/Entity)

Treatment Plans (Please Initial) *

Treatment/Discharge Summaries (Please Initial) *

Health/Medical Records (Please Initial) *

Case / Progress / Therapy Notes Academic (Please Initial) *

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, 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.

Print Name of Patient/Parent/ Guardian

Date

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.

Patient/Parent/Guardian

Date

Decline

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.

Patient/Parent/Guardian

Date

Decline

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.

Patient/Parent/Guardian

Date

Decline

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.

Patient/Parent/Guardian

Date

Decline

Integrity Speech Therapy may communicate with me/us by the method(s) checked below (Please check all that apply):

U.S. Mail Telephone Text Fax E-Mail (see below)

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.

Name

Email

example@example.com

Signature

Clear

Date

Please complete all the fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until canceled.

Card Type *

Cardholder Name (as shown on card) *

Card Number *

Expiration Date MM/YY *

CVC (3 digit number) *

Email address

example@example.com

Billing Zip Code *

I authorize INTEGRITY SPEECH THERAPY to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.

Cardholder's Signature *

Clear

Date *

Date

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)

Please Initial *

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.

Please Initial *

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.

Please Initial *

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

Name of Patient *

Signature of Legal Guardian *

Clear

Relationship to Patient

Date

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

Name of Patient

Please Select:

MANAGED CARE - WITHOUT A REFERRAL OR OUT OF NETWORK. I understand that my insurance contract with my health insurance plan(s) require a referral authorization from my designated primary care physician for certain medical services and/or requires me to be financially responsible for all or part of my visits. I understand that at this time I have the option to reschedule my appointment and return at a later date with an appropriate referral authorization. I have chosen to be seen by the provider without an appropriate referral or under an "Out of Network" option. Therefore, I agree to be personally responsible for payment of all charges incurred as described by my health insurance plan. POINT OF SERVICE OPTIONS. I understand that my health insurance plan(s) provide(s) me with several options. I have chosen to receive services from the provider under one of those options which requires me to pay a higher deductible,co-payment, or coinsurance according to the provisions that contract. PLAN BENEFIT LIMITS. I understand my physician has prescribed a treatment/service that is not covered by my health insurance plan(s). I am aware that I am financially responsible for all non-covered charges. SELF PAY. I acknowledge that I am a ‘Self Pay’ patient. Some reasons for my self-pay status may include but are not limited to having a no plan coverage, being seen without a valid referral or prescription script, receiving non-covered services or not having selected a PCP as required by my insurance plan. I understand that as a self-pay patient, I am not automatically eligible for a discount though I may apply for a discount based on family unit income and insurance status. By signing this form, I am certifying that I agree to be financially responsible for the patient due portion of my account and that I agree to pay an estimate of the amount due at the time services are rendered. If the actual charges exceed the estimate paid, I understand that I will be billed for the difference. Likewise, if the actual charges are less than the estimate paid, I will be entitled to a refund for the amount paid in excess of the actual charges.

Signature of Patient of Responsible Party

Clear

Date

Signature of Witness

Clear

Date

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.

Please read and acknowledge by checking:

I acknowledge that I have received a copy of Integrity Speech Therapy's HIPAA Notice of Privacy Practices thatfullyexplainstheusesanddisclosurestheywillmakewithrespecttomyindividuallyidentifiablehealth information. I have had the opportunity to read the notice and to have any questions regarding the notice answered to my satisfaction. I understand Integrity Speech Therapy cannot disclose my health information other than as specified in the notice. I understand that Integrity Speech Therapy reserves the right to change the notice and the practices detailed therein if it sends a copy of the revised notice to the address I have provided.

Name of Patient

Date

Signature of Patient or Legal Representative

Clear

Relationship to Patient

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

New Patient Form

Educational History

Consent for Services

Consent for Telehealth Consultation

Consent to Use the Telehealth By SimplePractice Service

CONSENT FORMS

Mode of Communication with Integrity Speech Therapy

Credit Card Authorization Form

Attendance/Cancellation Policy

Health Insurance Waiver Acknowledgement

Acknowledgment That You Have Received Our HIPAA Privacy Notice

HIPAA POLICY A NOTICE OF PRIVACY PRACTICES