Client Intake Form Demographic Information Last Name: First Name: of Birth: Sex: Diagnosis (if known): Parent/Guardian Name(s): Home Address: Parent #1 Phone: Parent #2 Phone: Parent #1 Email: Parent #2 Email: Primary Care Physician: Insurance Information Primary Insurance: ID#: Policy Holder Name: Group #: Policy Holder DOB: Deductible: Coinsurance: Copay: Patient Authorization I authorize the release of any medical information necessary to process any insurance claim. I authorize payment of medical benefits to the therapist for services rendered. Patient/Guardian Signature: : Page 1! of 11!
Authorization for Release of Medical Information I give Holistic Speech & Language permission to use or share my medical records, evaluation results, and treatment records with: Physician Name & Organization: Phone: Fax: This authorization will expire upon termination of services. I understand that: I do not have to sign this authorization. I will still be able to get treatment here even if I do not sign it. I am allowed to see or copy the health information that will be used or shared. I can take back this authorization at any time. I need to write to Holistic Speech & Language at holistic.language@gmail.com to do this. Any information that was used or shared before I took back the authorization cannot be returned. The person or organization that gets my health information because of this authorization may have the right to share it with others without my permission. Page 2! of 11!
Authorization for Release of Information I give Holistic Speech & Language permission to use or share relevant student records, evaluation results, and treatment records with: School Name (if applicable): Phone: Fax: This authorization will expire upon termination of services. I understand that: I do not have to sign this authorization. I will still be able to get treatment here even if I do not sign it. I am allowed to see or copy the health information that will be used or shared. I can take back this authorization at any time. I need to write to Holistic Speech & Language at holistic.language@gmail.com to do this. Any information that was used or shared before I took back the authorization cannot be returned. The person or organization that gets my health information because of this authorization may have the right to share it with others without my permission. Page 3! of 11!
Authorization for Release of Information I give Holistic Speech & Language permission to use or share relevant student records, evaluation results, and treatment records with: Previous Speech Therapist (if applicable): Phone: Fax: This authorization will expire upon termination of services. I understand that: I do not have to sign this authorization. I will still be able to get treatment here even if I do not sign it. I am allowed to see or copy the health information that will be used or shared. I can take back this authorization at any time. I need to write to Holistic Speech & Language at holistic.language@gmail.com to do this. Any information that was used or shared before I took back the authorization cannot be returned. The person or organization that gets my health information because of this authorization may have the right to share it with others without my permission. Page 4! of 11!
Authorization for Release of Information I give Holistic Speech & Language permission to use or share my medical records, evaluation results, and treatment records with previous therapy providers: ABA Therapist/Organization Name (if applicable): Phone: Fax: This authorization will expire upon termination of services. I understand that: I do not have to sign this authorization. I will still be able to get treatment here even if I do not sign it. I am allowed to see or copy the health information that will be used or shared. I can take back this authorization at any time. I need to write to Holistic Speech & Language at holistic.language@gmail.com to do this. Any information that was used or shared before I took back the authorization cannot be returned. The person or organization that gets my health information because of this authorization may have the right to share it with others without my permission. Page 5! of 11!
Acknowledgment That You Have Received Our HIPAA Privacy Notice Holistic Speech & Language 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 Holistic Speech & Language is 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. By signing this page, you are saying that you have been given a copy of our privacy notice. Page 6! of 11!
Informed Consent I hereby grant Tiffany Lockhart, M.A., CCC-SLP permission to evaluate and treat (client name) according to her clinical skills Page 7! of 11!
Attendance Policy Thank you for choosing Holistic Speech & Language. We want to provide the best possible services to all of our clients. We will do our best to schedule appointments that meet your needs. Regular attendance is important to your/your child s success. We ask that you follow the attendance policies outlined below: 1. Cancellations: Please call us at least 24 hours in advance to cancel your appointment. Exceptions to this policy are made in cases of illness or emergency. 2. Missed Appointments: If you cancel or do not attend 2 sessions in a row without prior notice, Holistic Speech & Language will put your services on hold until scheduling conflicts can be worked out. If you miss an appointment without prior notice, you will be responsible for the original service fee (applicable for private pay and insurance clients). 3. Late for Appointments: If you are more than 15 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). Your speech-language pathologist will try her best to arrive on time for your appointments. Please be aware that construction, traffic, parking, etc. may affect arrival time and reduce your appointment length. If we are more than 5 minutes late for an appointment due to unforeseen circumstances, we will try our best to stay an extra 5 minutes to accommodate. 4. Clinician Cancellations: If your speech-language pathologist is not able to attend your appointment, you will be contacted as soon as possible. Please be sure that our office knows the best way to reach you. Every effort will be made to reschedule your appointment in a timely manner. To cancel an appointment, please call (206) 409-9964 or email holistic.language@gmail.com. I have read and agree to the attendance policies outlined above. Page 8! of 11!
Payment Policy Thank you for choosing Holistic Speech & Language for your speech-language pathology needs. This is an agreement between Holistic Speech & Language and you for payment of services provided. Please read the following information carefully: Regence, Premera, & Lifewise Insurance: Holistic Speech & Language will bill your insurance provider for all services rendered. Please request a referral from your doctor before your first session. We are required to keep a prescription on file for insurance purposes. Deductible, coinsurance, and/or copayment are due at the time of service, unless otherwise discussed with your clinician. Should your coverage change or be denied by the insurance company you are responsible for paying Holistic Speech & Language the full amount for services you or your child receives. Private Pay & Out-of-Network Insurance: Holistic Speech & Language is considered an out-of-network provider for most insurance companies, with the exception of Regence and Premera. We do not bill insurance for out-of-network services provided. Instead, families may submit claims to their insurance. Payment is due in full at the time of service. Note: If you plan to submit bills to your insurance company for reimbursement, you will be provided with an invoice containing all information your insurance requires. You can then submit a claim form for reimbursement. Before initiating services, it is your responsibility to: Check with your insurance company before your first visit to find out what speech and language services they will pay for. Find out what information the insurance company needs. o o You may need a referral from your doctor. You may need permission from the insurance company, called pre-authorization. Referrals and pre-authorizations do not guarantee that insurance will pay for services. You will be responsible for all insurance inquiries and correspondence. If you need assistance in speaking with your insurance company, Holistic Speech & Language is more than happy to assist you. Please note that a consultation fee will be incurred for each insurance contact (please see Services tab on our website for fee details). Page 9! of 11!
Forms of Payment Accepted: Credit/Debit- (Visa, MasterCard, Discover), HSA Card, FSA Card, Check, Cash. Online payments- I use the Intuit payment system for online payments. I will send you an invoice containing a link to pay your bill online via a bank transfer. I use this method for clients I see at school without parents present. Square- Accepts credit/debit cards (Visa, Mastercard, Discover, American Express). Also accepts HSA and FSA cards. I use this method for clients I see with parents present for services. Cash/Check- Please provide the exact cash amount. If writing a check, please make checks payable to Holistic Speech & Language. Returned Checks/Insufficient Funds: You will be charged a $30 fee for each returned check and applicable fees for denied credit/debit payments. Late Cancellation/No-show Fees: Late cancellations due to unexpected illness will not be charged. However, you will incur fees if you accumulate more than 4 late cancellations due to illness. If you miss an appointment without prior notice, you will be responsible for the full service fee. Past Due Accounts: Accounts past due are not permitted. You are expected to pay in full at the time of service, unless otherwise discussed. Holistic Speech & Language is happy to discuss alternative payment arrangements if needed. Please do not wait until you are not able to pay to discuss payment options, otherwise services will be put on hold until payments are received in full or a payment plan is established. Accounts past due will be charged a 5% fee for each day past due. Accounts more than 2 months past due without an established payment plan will be sent to a collection agency. You will be responsible for collection costs, as well as attorney fees and court costs. By signing below, I confirm that I understand and agree to the payment policies outlined above. Client s Name Page 10! of 11!
Liability Disclaimer Holistic Speech & Language does not provide liability insurance for the protection of individuals, groups, organizations, businesses, spectators, or others who may participate in Holistic Speech & Language services. In consideration for your participation in services provided by Holistic Speech & Language, you hereby release and forever discharge Holistic Speech & Language and its colleagues and clients, from any and all actions, causes of actions, and claims and demands for any damage, loss, or injury which may be sustained by participating in services provided by Holistic Speech & Language. This release extends and applies to all unknown, unforeseen, unanticipated and unsuspected injuries, damages, and loss and liability. I hereby agree to indemnify Holistic Speech & Language and its clients from liability for any damage, loss, or injury which may be sustained while participating in services provided by Holistic Speech & Language. Page! 11 of! 11