Case History/Office Docs

Speech, Language & Learning Center of Tennessee, LLC

1511 Nashville Hwy. Ste A, Columbia, TN 38401

Office: 931.490.7770 Fax: 931.490.7771

925 S. Church Street B2000

Murfreesboro, TN 37130

Office: 931.490.7770 Fax: 931.490.7771

1311 South Locust Ave. Suite 101, Lawrenceburg, TN 38464

Office: 931.766.6374 Fax: 931.766.6433

Welcome to our Center!

Speech, Language & Learning Center of Tennessee is a private practice pediatric therapy clinic providing speech/language, autism, feeding, dyslexia, and occupational therapy services to children in our two locations in Columbia and Lawrenceburg, Tennessee. Our staff members are certified in many specialty areas of practice. We also provide services through school systems and private agencies. You have been referred to us by your physician, teacher, or friend and we appreciate the trust and opportunity to serve you. Prior to your first appointment, please complete the following information packet, answering each question as thoroughly as possible. Please try to include reports from other sources, or sign a release so that we may obtain those records prior to your evaluation. Also, please contact your insurance company to determine their policies for covering our services. All information that you provide to us will be held strictly confidential. This packet will allow us to know you better before you arrive and will help us appropriately complete the evaluation. Carla Clayton is our Billing Manager; Chelsie Roberson, (Lawrenceburg) Amy Bailey (Columbia) is our office personnel. Please let them know if you have any questions and please feel free to call the owners to personally discuss how we may assist you or your family.

Office Policies

PLEASE READ the following office policies carefully. We will be happy to address questions or concerns.

Billing Information (see Terms of Agreement Form)

We do provide third-party billing to your insurance company. However, you are ultimately responsible for your bill. We will NEVER assure you that your insurance will cover your services! Therefore, we ask that you help us with necessary items to secure proper payment for services such as doctor's orders, authorization numbers, precertification, etc.

If we are directly billing your insurance company for you, we must have a copy of your insurance card. We will call your insurance company to verify your policy and coverage but it is your responsibility to check your policy for coverage guidelines. You must also keep us notified of any changes to your policy. We will carry coverage for three months, which is the average time it takes to hear from insurance companies. If, after three months, we have not been reimbursed, we will send that bill directly to you. You will be responsible for your deductible and co-pay at the time of the visit. Services will be suspended when debt reaches $250.
Waiting Room Policy

Please check-in at the reception window when you come into the office. We try to run our therapy sessions as close to the hour and half-hour as possible. If you have to wait longer than 10 minutes, please inquire as to the delay. For parents bringing children to therapy; you may wait in the waiting room. We ask that you not leave the office! If your appointment is for an hour, you may speak with the Office Manager about leaving briefly, in which case you will need to leave a cell number and return promptly to pick up your child.

Cancellation and Absences (see Attendance Policy and Sickness Policy)

If we ever need to cancel or change your appointment we will make every effort to give you advance notice. Please do the same for us. We ask that you call and leave a message on the answering machine if you are running late or will be absent. We will return your call to reschedule. We kindly ask that you do not only contact staff on their personal phones during business hours unless the message is urgent. Your attendance at all sessions is important to your progress and a missed session is time wasted for us. You will be asked to agree to, and sign, an attendance policy. We have a waiting list for our services, therefore we seriously adhere to this policy. If you are 15 minutes late for your appointment, it will be re-scheduled, as you will not be able to receive the full benefit from the therapy in such a short time. Please do not bring your child to therapy if he/she has been ill, especially if they have had a fever in the past 24 hours or have had infections or a virus (pink eye, chickenpox, ear infection, etc). We have many medically fragile patients in and out of the office who do not need to be exposed unnecessarily.

Snow Closings

We will no longer follow the school system's schedules for closings due to weather. In the event of bad weather, you will hear directly from your therapist(s) regarding the SLLC closure and canceled therapy. If you do not hear from your therapist, we will be OPEN, please plan to attend therapy (even if schools are closed). Any closings are also always posted on our social media pages.

Parking is allowed in front of our office buildings.

Smoking Smoking is not allowed in any of our buildings or on the sidewalk directly in front of our doors.

Home Practice and Progress

No matter what your diagnosis, your rate of progress in therapy depends on your work when you get home! It is vitally important for you to keep up with goals and treatment plans and to follow all instructions. It is suggested that all patients keep a notebook. After each session, a progress note is written by your therapist and sent to your insurance company. We MUST document progress over several sessions for the company to continue coverage BUT MOST IMPORTANTLY WE MAKE PROGRESS FOR YOU!

We look forward to working with you. If you ever have any questions or concerns please let your therapist(s) or owners know! We want to hear your comments. They are important for the success of our Centers.

HIPAA/PRIVACY POLICY

In this paperwork, you will find a "Notice of Privacy Practices" which is a modified version of our full "Notice of Privacy Practices" which is posted in our waiting rooms and a full copy is available to you upon request from any staff member.

Thank You!

The Speech Language & Learning Center of TN, LLC
Image & Video Release Form

Speech, Language, and Learning Center of TN uses the www.sllcenter.com website, our Facebook and Instagram pages, brochures, and seminars to market our services and provide educational information to the public. Please read your choices carefully and select one option and provide your signature as consent or refusal to use your child's photograph and/or video of the session and names for these purposes.
*

I hereby consent that my child's photograph may be used by Speech, Language, & Learning Center of TN for marketing purposes or to provide information to the public regarding the Centers including television, web pages, brochures, newspapers, and teleconferences. No last names will be used.I do not wish for my child's image or video to be used in any way by Speech, Language, & Learning Center of TN.
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Financial Terms of Agreement

This form contains information regarding payment for our services. Please read it carefully and discuss any questions or concerns with our office or billing managers prior to receiving services.

In-Network Commercial Insurances: We are currently in-network providers for BCBS United Healthcare Tricare UMR

If your child is covered by a commercial insurance policy, you will be asked to pay for the evaluation and therapy at the time service is rendered. The office will discuss this cost with you as the cost will vary according to which type of evaluation your child will be having. After the services are completed, they will be filed with your insurance. If insurance covers the services and pays us, you will be reimbursed by the SLLC of TN. Should therapy not be covered under your child's plan or the deductible not met, you will be asked to pay for each visit at the time of service.

Being in-network does not guarantee that your child's services are covered by your insurance. It is your responsibility to check your coverage policy with your insurance company. Depending on the policy, our staff is sometimes able to check on coverage for you but we will never guarantee that your insurance will cover our services.

TennCare Insurances:

We are currently in-network providers for:

TennCare Select, BlueCare, Amerigroup, and United Healthcare Community Plan.

If your child is covered under a TennCare plan, you will not be responsible for payment before the services are rendered. However, if you have TennCare and you fail to notify us that your TennCare has expired, that you have changed TennCare companies, or if you failed to provide any other information you will be financially responsible for payment for services.

Cover Kids Insurances:

Patients will pay co-pays for child's therapies prior to the service.

Private Pay:

Private pay patients are patients who choose to pay privately and not have us file their insurance, patients whose insurance has not paid all, or the complete allowed portion of their filed claim. As stated above, those patients will be asked to pay at the time of service.

We are NOT in-network with: Aetna, UMR, Cigna, and Humana.

We will attempt to contact these companies prior to service. If we can make arrangements for reimbursement, we will file for services on your behalf. If we do not obtain prior authorization or an agreement with your insurance company, we will expect payment from you directly at the time of service. If insurance covers the evaluation or therapy services and pays the SLLC, you will be reimbursed by the SLLC.

Check and sign below:*

I give permission for evaluation and treatment by the therapy staff of Speech, Language & Learning Center of Tennessee, LLC.I understand that I am personally responsible for the payment of services rendered to me by Speech, Language, & Learning Center of TN staff, regardless of insurance payment. Furthermore, I understand that it is my responsibility to check my insurance benefits prior to receiving services.I understand that the SLLC of TN staff will be happy to help me with insurance issues but that cannot assure me that my services are covered.I authorize Speech, Language & Learning Center of TN, LLC to release information to my insurer if necessaryI will promptly pay any outstanding or non-reimbursable amounts after insurance payment or denial to Speech, Language & Learning Center of TN, LLCIf insurance denies coverage, I agree to pay for services at the time they are rendered and understand that a balance carried over 6 months will be sent to a collections agency.I hereby authorize my insurance company to remit payment directly to Speech, Language, & Learning Center of TN, LLC.I hereby understand that services may be discontinued should outstanding debt reach $250.I understand that there is absolutely NO guarantee that my child will progress with any given therapy services. I expect the therapy staff to render the best services possible but understand that my child's progress depends on other factors, including but not limited to, attendance and my involvement as a parent. Payments will not be refunded due to lack of therapy progress. I can expect the SLLC of TN staff to notify me if my child is not making reasonable progress. I have the right to remove my child from therapy or ask to try a new therapist within the Center.
METHODS OF ACCEPTED PAYMENTS:

Via email through our portal; set up through our office staff

Debit or Credit card may be kept on file for phone payments through the office staff

Auto bill to your credit card kept on file at the time of service with signed permission
Signature of Responsible Party: *

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The Speech Langauge and Learning Center of TN, LLC

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. You have a right to obtain a copy of this notice upon request.

Patient Health Information: Under Federal Law, your patient health information is protected and confidential. Information includes information about your symptoms, test results, diagnosis, treatment, and related medical information. Your health information also includes payment, billing, and insurance information.

Individual Rights: You have the following rights with regard to your health information. Please contact the person listed below to obtain the appropriate form for exercising these rights. Request restrictions: You may request restrictions on certain uses and disclosures of your health information. We are not required to agree to such restrictions, but if we do agree, we must abide by those restrictions. You may ask us to communicate with you confidentially by, for example, using a cell phone number only, or sending mail to a certain address. Inspect and Obtain Copies: In most cases, you have the right to review or obtain a copy of your health record. There may be a small charge for the copies if over ten pages are requested. Amend Information: If you believe that the information in your record is incorrect, or if important information is missing, you have the right to request that we correct or add to the existing information.

Our Legal Duty: We are required by law to protect and maintain the privacy of your health information, to provide this notice about our legal duties and privacy regarding protected health information, and abide by the terms of the notice currently in effect.

Complaints: If you are concerned that we have violated your privacy rights, or if you disagree with a decision we made about your records, you may contact the person listed below. You will not be penalized in any way for filing a complaint.

Becky Brown & Kylie Mansfield

Privacy Officers

1311 South Locust Avenue Suite 101

Lawrenceburg, TN 38464 (10/20))

Speech, Language & Learning Center of TN, LLC

(revised 06/2021)
I give my authorization to the staff of Speech, Language & Learning Center of TN, L.L.C., to discuss any treatment issues concerning me to: (name and relationship)
*

I have been given a copy of my rights and the Center's Privacy Policy and understand that the full SLLC of TN Privacy Notices are posted and available to me.I give my permission for the staff at the SLLC of TN to leave a message on my voice mail or to any person answering my personal phone.I give my permission for the SLLC of TN staff to contact me at my place of employment.I give my permission to the SLLC of TN staff to fax any information regarding treatment to my physician's office, or another agency that may be covering our services.If there is any information I do not want discussed or a message to be left at my home or at my place of employment, I will notify the SLLC of TN staff of this in writing.
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Speech, Language & Learning Center of TN, LLC

(revised 06/2021)
SLLC of TN Attendance Policy

Your child was referred to the SLLC of TN by his/her pediatrician or health care professional in order to receive services to assist in their growth and development.

In order to ensure that your child receives quality services and exhibits excellent progress in therapy, it is necessary that he/she attend all scheduled sessions. Without consistent attendance, progress cannot be expected.

In addition, we are required to submit your child's attendance report to his/her insurance company. Missed appointments may cause the insurance company to deny further services to your child. When your child misses a scheduled appointment, it takes time away from another child who is on our waiting list and wanting an appointment. Finally, we promise to do our best to move your child through therapy as quickly as possible and that can only happen with regular attendance and parent participation.

Please review the following Attendance Policy and indicate agreement to these terms by signing below.

I agree to bring my child to all therapy sessions. I will be on time for sessions and participate consistently. I will call the office if we are going to be late. I understand that if I am over 15 minutes late, the appointment will be canceled. I understand that if I fail to show up for an appointment without calling more than two times within a three-month period, my child will be considered a "no show" and will be removed from therapy and discharged. If I have an unexpected, but short-term emergency that will make absences necessary, I may request a temporary leave (no more than two weeks) until able to resume services without jeopardizing current enrollment, although appointment times may change. After a total of 3 absences out of 12 scheduled appointments (for children coming once a week), or 4 absences out of 24 scheduled appointments (for children coming twice a week) within a three-month period my child will be discharged from his/her standing appointment time. (If the child has a doctor's excuse for a significant illness such as the flu or strep we will make allowances) If a patient is discharged due to attendance, he or she may return after 3 months. The parent(s) will be responsible for scheduling appointments.

I have read and understood the terms of this Attendance Policy.
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Speech, Language & Learning Center of TN, LLC

Sickness Policy:

If your child has a contagious illness. they cannot come to the SLLC of TN until:

They have been cleared by a doctor stating that they are no longer contagious and are clear to be around other children (Usually 24 hours after antibiotic treatment has begun and/or 24 hours after symptoms have subsided: depending on the illness), Your child cannot attend therapy with a fever of 100.0 degrees or higher and must be fever-free for a minimum of 24 hours before returning to therapy. That means fever-free without the aid of a fever-reducing substance.

Reasons why the child cannot come to therapy:

Fever of 100.0 degrees or higher

Hand Foot Mouth Disease (Herpangina)

Cold with yellow or green nasal discharge Productive cough

Persistent phlegmy cough

Gastroenteritis (Stomach Flu) Persistent diarrhea (even if a reaction to antibiotics)

Ringworm

Scabies

Coxsackie Virus

Mumps

Croup

Flu

Vomiting

Impetigo

Pink Eye

Chicken Pox

MRSA

Head Lice

Contagious Styes

Fifth Disease (Slapped Cheek Disease)

ANY type of rash or blisters

ANY symptoms of COVID-19, or any direct exposure in the last 14 days.

These are just examples of contagious illnesses when your child needs to stay out of therapy. Each individual case is different and may require more or less time out - but will always require a doctor's note to return stating that the child is totally well and non-contagious in order to return. If you feel that your child is sick with a contagious illness, please verify with a doctor that your child is clear to come to therapy before bringing him/her. This is for the protection of your child and all other children present, many of which are medically fragile. Cancellations due to sickness made prior to your child's therapy session will not count against your child's Attendance Policy.
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Speech, Language & Learning Center of TN, LLC

Authorization to RELEASE/REQUEST Patient Information
Patient Name:*
DOB:*
Parent's Name:*
Address:*
Phone Number:*
Please enter a valid phone number.
Other:
Information is being released/requested to/from:
Name:*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Specific type of information to be disclosed:
Purpose:
*** This is an authorization for Speech, Language & Learning Center of TN, LLC, to convey to you any and all information relative to my treatment.
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SPEECH LANGUAGE & LEARNING CENTER OF TN, LLC

CLINIC POLICY
We are committed to providing your child with the best possible care. Please review our clinic policies listed below to help us achieve this goal.

_____ THERAPY START TIMES AND SCHEDULES:

Arrive a few minutes before your therapy session begins so your child can take care of personal needs. We make every effort to begin therapy sessions at the scheduled time, and in order for your child to receive the maximum benefit from each session, it is imperative that you arrive on time. Patients will not be able to receive therapy if they arrive 15 minutes after their scheduled therapy time and will not be able to be treated past the end of their scheduled appointment time, as this often interferes with another child's session. In order to meet Health Insurance documentation requirements, all therapists are required to document therapy activities and goal progress in the last few minutes of each session.

____ DROP OFF/PICKUP:

Parents must check their child in at the front desk at the beginning of each therapy session, and walk into the clinic or onto the sidewalk to pick up their child at the end of the session. Any authorized individuals who pick up your child must come inside and present a proper ID to the front office. If you opt to leave your child in the care of the therapist during the session, you must arrive to pick them up 5 minutes before the session ends. If you arrive after your child's session has ended more than TWICE, your child will be removed from their standing appointment time and placed on the waitlist. For safety reasons, we cannot pick up and drop off at your car.

____ CHILD SUPERVISION:

All clients and siblings must be supervised by parents or caregivers at all times. while all children are adored here at the SLLC of TN, siblings can often be a distraction that may interfere with the client's success during a therapy session. If a therapist has requested a parent to attend the evaluation or therapy session, siblings are asked to not be present during this time. Please do not ask the front office staff or therapist to watch your child.

____ VIOLENT BEHAVIOR:

We reserve the right to refuse further treatment following a significant incident of violent behavior from a child. If a violent incident occurs, the parent will be notified of our inability to safely control and treat the child.

____ CONFIDENTIALITY:

We maintain a strict confidentiality policy for all of our clients. This is for your protection. Sessions will not be discussed in the waiting room. You may schedule an appointment to discuss your concerns with your child's therapist.

I have read the above and will comply with all Speech Language & Learning Center of TN, LLC's Clinic Policy guidelines.
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Allergy Form
Patient Name:

First NameLast Name
Patient DOB:

MonthDayYear
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Does your child have any allergies:

YESNO
FOODS:
Reactions:
Medications:
Reactions:
Insects:
Reactions:
DOES YOUR CHILD HAVE ANY OTHER ALLERGIES (I.E., CHEMICAL, FIRST AID CREAM/LOTIONS, PLANTS, ANIMALS, ETC.)

YESNO
IF YES, PLEASE LIST AND INDICATE TYPE OF REACTION.
IS THERE A HISTORY OF ALLERGIC REACTIONS IN YOUR FAMILY THAT MAY AFFECT YOUR CHILD THAT WE SHOULD BE MADE AWARE OF?

YESNO
DOES YOUR CHILD SUFFER FROM ASTHMA? IF YES, PLEASE PROVIDE YOUR THERAPIST(S) WITH MEDICAL ADVICE.

YESNO

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The Speech Language & Learning Center of TN, LLC

Speech, Language & Learning Center of TN, LLC

Speech, Language & Learning Center of TN, LLC

SPEECH LANGUAGE & LEARNING CENTER OF TN, LLC

Additional Authorized Pick-ups Child's Name:

Allergy Form

Speech, Language & Learning Center of TN, LLC