Person Responsible for Payment: (Insurance Subscriber or Guardian) Home Phone: Work Phone: Cell Phone: Email: * APPOINTMENT REMINDER How would you like your appointments confirmed Phone Email * PRIMARY CARE PHYSICIAN Primary Care Physician’s Name: Group/Practice Name: Phone INSURANCE INFORMATION
PLEASE DO NOT ENTER “SEE CARD” in Lieu of providing the required information!
• Please be ready to also present your insurance card and ID to receptionist so that copies can be added to your file
Primary Insurance: Policy Holder DOB: Insurance Phone Number Group Number Policy Number Person Responsible for Payment: (Insurance Subscriber or Guardian) Relationship to Patient Secondary Insurance: Policy Holder Name: Policy Holder DOB: Insurance Phone Number: Group Number: Policy Number: Person Responsible for Payment: (Insurance Subscriber or Guardian) Relationship to Patient Is there an injury due to an accident? Date and Place of accident: Was the accident work related? Name, Address, and phone number of attorney or workman’s comp carrier: EMERGENCY CONTACT INFORMATION: Phone Relationship to Patient: How did you hear about this practice? By signing below you agree that all of the information provided here is up to date and correct to the best of your knowledge. TREATMENT AUTHORIZATION I agree to allow Frederick SLP to provide speech-language pathology services for myself or child. In addition: Print Patient’s Name Date Relationship INSURANCE BILLING AUTHORIZATION
By signing the following agreement, you are allowing Frederick SLP to submit claims for services to the respective insurance provider
on your behalf.
Signature and information included here also represent your consent for the provider to pay Frederick SLP directly for her services
Any deductible or co-pay is applicable according to the terms of your individual policy.
If there is a balance that is outstanding after submission and any subsequent attempts at insurance coverage, the person responsible
for the payment will be expected to pay Frederick SLP in full.
I request that payment of authorized (insurance provider)
benefits be made either to me or on my behalf to Frederick SLP for any services furnished to me by Frederick SLP. I authorize any holder of medical information about me to release to the (insurance provider)
and its agents any information needed to determine these benefits or the benefits payable for related service.
Credit Card Authorization Form (Optional) I
authorize Frederick SLP to keep credit card information on file and use this information to charge and pay for speech therapy sessions. I understand that I will be notified by invoice of the amount and nature of each charge.
Frederick SLP will not use your credit card information for anything other than payment for services listed above. Frederick SLP will not release your credit card information to anyone aside from the service providers allowing for the transaction to be completed. Your information will be kept in a secure location.
HIPAA – YOUR PRIVACY RIGHTS 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.
Frederick SLP is required by law to keep your health information safe. This information may include:
Notes from your doctor, teacher, or other healthcare provider
Your medical history
Your test results
A government rule, called the Health Insurance Portability and Accountability Act, or HIPAA, requires that you get a copy of this privacy notice. We will ask you to sign a paper saying that you have been given this notice.
Read and refer to this notice at any time to see how your health information can be used and who can see it. How Your Health Information May Be Used or Shared:
We may use or share your health information without your permission for the following reasons:
Treatment: we may share information with doctors and other health care providers who care for you. Payment: We may use and share information about the treatment you receive with your insurance company or other payer to receive payment for services. This may include sharing important medical information.
Health Care Operations: We may use and share your health information to run the clinic and be sure that all patients receive good care.
Abuse and Neglect: We may share your health information with government agencies when there is evidence of abuse. Neglect, or domestic violence.
Threats and Health and Safety: Your health information may be shared if we believe that it will prevent a threat to your health and safety or the health and safety of others.
As Required by Law: We will share your information when we are told to do so by federal, state, or local law. We will also share information if we are asked by the police or courts.
By signing below, you are agreeing to the terms stated above: Payment Policy:
It is the policy of Frederick SLP that payment is due at the time of service unless other financial arrangements are made in advance. We require all patients to pay their copayment at the beginning of each visit. Coinsurance will be billed at the end of each month and a statement will be sent to your home unless requested otherwise. At the conclusion of your visits with us you may be billed for any outstanding balances.
If you are covered by health insurance with Speech Therapy/Occupational Therapy benefits, we will be happy to bill your insurance. Please provide your insurance information to the front office staff and we will verify your coverage as a courtesy. Accepting your insurance does not place all financial responsibilities onto this practice, and you will be held accountable for any unpaid balances by your plan.
Although we are contracted with most insurance carriers, our services may not be covered by your particular insurance plan. Being referred to our clinic by another physician does not necessarily guarantee that your insurance will cover our services. Please remember that you are 100 percent responsible for all charges incurred: your physician's referral and our verification of your insurance benefits are not a guarantee of payment.
If for some reason your account accumulates a balance of $200 or higher, Frederick SLP has the right to postpone services until a payment is made.
Past Due Accounts: Accounts that are 30 days past due will have a 5% charge added to the total balance. This cycle will continue at 60 days past due with additional 5% added to the balance. Once the account reaches 90 days past due, it will be sent to collections.
If you are having trouble paying the balance on your account, there are payment plans available in certain cases. The office manager can be reached at 301-668-1852 to discuss a payment plan with you.
By signing below, you are agreeing to the terms stated above: COVID IN OFFICE PRECAUTIONS AND PROCEDURES As of 11/2020
You will see the same team present in the office for your weekly visits. At the beginning of each visit, clients/parents will be asked a series of screening questions and will have their temperature taken using a contact-less thermometer.
If your child or anyone else in your home is displaying any signs of illness including, but not limited to coughing, runny nose, or fever we will not be able to see you in person until symptoms have not been evident for five days. In the meantime, we will be happy to schedule a telehealth visit with your child.
We ask that you refrain from in office visits for 14 days, if anyone the patient has direct contact with travels outside of the state. The same goes for if anyone has had direct contact with someone who has tested positive for COVID-19.
We ask that you arrive 5 minutes prior to your child’s scheduled appointment time to comply with our safety precautions and allow for time to transition your child into the office. Our office building in now open to the public. We are located on the 4th floor. When you arrive, please bring your child up to our office where we will conduct our COVID screening. If everything checks out, we will then begin th session.
Clinicians will be wearing masks, gloves and eye protection during sessions and parent interactions.
One guardian will be permitted in the waiting room during the clients session. Parents or guardians will be required to wear masks and maintain social distancing when interacting with staff members. If you choose to wait in your vehicle, please make sure you are back up in our waiting room ready to pick up your child at the end of the session time.
Clients age 5 and under will not be required to wear a mask at this time. Although if they are able to tolerate the mask they are strongly encouraged particularly for transitions.
Clients will be asked to disinfect their hands when entering the office.
At the end of your sessions, clinicians will be available for a 5 minute follow up discussion. If you wish to continue your conversation with your child’s SLP after the initial 5 minutes, an additional follow up conversation can be scheduled with your therapist via phone or email to provide you with more information. Please speak with your individual therapist for additional details.
Due to the high demand for in person sessions and the limited availability of appointments at this time. We will be enacting a modified no show policy at this time. If you no show for any appointments, you will be removed from the in office visit schedule, however, you would be welcome to continue teletherapy session
We know these are a lot of changes and precautions, but we want to keep everyone as safe as possible.
COVID-19: Screening Checklist – for Visitors
On March 13, 2020, CMS and CDC updated guidance on restricting all
Frederick SLP visitors and non-essential healthcare personnel, except for certain compassionate care situations. ALL individuals (staff, other health care workers, family, visitors, government officials, etc.) entering the building must be asked the following questions: 1. Has this individual washed their hands or used alcohol-based hand rub (ABHR) on entry? 2. Ask the individual if they have any of the following respiratory symptoms? OR at least TWO of these symptoms • If YES to any, restrict them from entering the building.
3. Have you come in contact with anyone who has tested positive for COVID within the last two weeks? Allow entry to building and remind the individual to: Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.
Frederick SLP has put in place preventative measures to reduce the spread of COVID-19; however, the office cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending in-person, Face-to-face therapy sessions, could increase your risk and your child(ren)’s risk of contracting COVID-19.
By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending their speech sessions, in office, and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 while in the office may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Frederick SLP’s employees, volunteers, and program participants and their families.
I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at Frederick SLP. On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless of Frederick SLP and its employees if I or my children contract COVID-19 while attending speech therapy.
Adult Case History Date of Birth Age Phone (H): Phone (W) Phone (C) Language(s) Spoken: Is English your primary language? If no: What language(s) is/are spoken at home: Is an interpreter needed? Emergency Contact Name: * Emergency Contact Phone Relation to Self Physician(s) Practice Phone Do you have a referral? Reason for visit: Have you received speech-language pathology services before? If yes, When: Where: Medical History: List illnesses, surgeries, injuries, or medical issues: List Medications taken regularly: Known Allergies: Have you had problems with or changes in (check all that apply): Have you had a hearing test: Do you wear a hearing aid(s): Have you had problems with or changes in (check all that apply): Vision: have you had a vision test? If yes, when: Do you wear contact lenses: Teeth: Do you wear dentures? Do you have breathing problems? Do you have swallowing problems? Education and Work History: Highest degree received: Occupation: Are you currently working: Recreational Activities Is there anything else you would like us to know: ATTENDANCE AND CANCELLATION POLICY Revised and Effective January 1, 2021
Due to the high volume of last minute cancellations, late arrivals and no-shows Frederick SLP has revised our cancellation policy to better serve our clients. We are a rapidly growing practice with many incoming patients on our wait list. Due to the high demand, all policies below will go in effect and be enforced January 1st 2021.
Cancellations/No Shows -
Except for emergency situations, all appointments must be canceled at least 24 hours in advance by calling or emailing our office administration. We consider the following to be examples of NON EMERGENCY reasons to cancel an appointment: vacations, pre-scheduled doctor appointments, family events, parties, recreational events, play dates, after school activities, lack of child care, holiday weekend, school holiday, the day before or after a holiday and schedule conflict.
All appointments that are not canceled at least 24 hours in advance of the scheduled appointment, will be charged a late cancellation fee of $95. This fee is not covered by insurance or other third party payer and must be paid in full no later than your next appointment. Patients will not be seen if the late cancellation fee has not been paid in full. If no-shows and cancellations reach a certain frequency, your appointment will be removed from the schedule.
We understand that delays can happen; however, the therapists adhere strictly to the scheduled time for the start of the therapy sessions. We ask that you arrive 5-10 minutes before the start of your appointment to allow for the session to begin on time. For billing purposes, clients who are late 10 minutes or more will not be able to be seen unless the client chooses to pay out of pocket.
MY SIGNATURE BELOW INDICATES THAT I HAVE READ THE ABOVE POLICY, UNDERSTAND AND ACCEPT THE TERMS AND CONDITIONS.