TELEHEALTH - Frederick-slp

Welcome!

We want your experience with us to be as pleasant as possible!
In order to save you time when you arrive, please fill out the following forms before your first visit.
Your first appointment will last about 1 hour and will conclude with a plan for treatment. Please bring any questions you may have to this appointment. It’s a good idea to write your questions down so that we may address all of your concerns.

If you are planning on using insurance for your sessions, please contact your insurance provider to get these questions answered at the start. We will submit paperwork on your behalf directly to the insurance providers, but we also suggest you reach out directly to your insurance provide and ask these questions:

Will they cover Speech Therapy?
Do you have a co-pay/co-insurance for these visits?
Do you have a deductible that needs to be fulfilled?
How many visits are you allowed for Speech Therapy treatment per year?
Do you need a doctor’s order or referral?
Do you need preauthorization?

We collect the copayments, coinsurance and deductibles at the time of service. Please arrive about 10 minutes before your appointment so that we can collect your information and get you in to see the therapist as soon as possible.

The following is a checklist that needs to be completed at the time of your first appointment:

Patient Information Sheet
Treatment Authorization Sheet
Payment Policy
Authorization for submitting insurance payment information
Acknowledgement of receipt of HIPAA Privacy Notice
Credit Card Authorization Form (optional)

Thank you for choosing Frederick SLP for your speech therapy. Let us know if you have any questions before you arrive. We look forward to meeting you!

Sincerely,

- Step 1 of 3

Patient’s Full Name *

First

Last

Date of Birth

Female
Male

Home Phone

Work Phone

Cell Phone

Email *

Address

Address Line 1

Address Line 2

City

State

Zip Code

APPOINTMENT REMINDER

How would you like your appointments confirmed

Phone Call
Email

Name of Contact

Phone

CARE PHYSICIAN

Primary Care Physician’s Name:

Group/Practice Name:

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

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 Name:

Policy Holder DOB:

Insurance Address:

Insurance Phone Number:

Group Number:

Policy Number:

Secondary Insurance:

Policy Holder Name:

Insurance Address:

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

Place of accident:

Was the accident work related?

Name, Address, and phone number of attorney or workman’s comp carrier

EMERGENCY CONTACT INFORMATION:

Name:

Phone:

Relationship to Patient:

How did you hear about this practice?

Doctor
Friend/family member
Self
Insurance Provider
Internet
Other

By signing below you agree that all of the information provided here is up to date and correct to the best of your knowledge.

Patient or Guardian Signature

Date

TREATMENT AUTHORIZATION

Please select:

I have seen and agree with the treatment goals and therapy plan
I agree to attend scheduled therapy sessions (see attendance policy).
I agree to participate in my child’s/loved one’s treatment, as appropriate.
I understand that my child/loved one may be given work to do at home. I agree to help my child/loved one do this work to help with treatment goals.

Print Patient’s Name

Date

Patient or Parent/Guardian Signature

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 where appropriate.
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.

Signature Form For (insurance provider)

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)

Name

and its agents any information needed to determine these benefits or the benefits payable for related service.

Signature

Date

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 co-payment 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.

Account Accumulation:

If for some reason your account accumulates a balance of $200 or higher, Frederick SLP has the right to postpone services until 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.

Payment Plans:

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:

Signature

Date

Credit Card Authorization Form

Your Name

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.

Type of Credit Card: VISA MASTERCARD AMERICAN EXPRESS DISCOVER

HIPPA Compliance Form - Telehealth

Please note Frederick SLP will communicate and correspond with you via e-mail on a regular basis. At times we may transmit personal and confidential information to you regarding your child’s treatment. We will use reasonable means to protect the security and confidentiality of e mail information sent and received; however, Frederick SLP cannot guarantee the privacy and security of such information. It is your duty to protect your e-mail account, password, and computer against access by unauthorized people. Frederick SLP will not be liable for anyone inappropriately using or accessing your e-mail. You may revoke your authorization for Frederick SLP to communicate with you by email at any time by written request.

Frederick SLP also provides tele-practice services. The platform the sessions are hosted on are HIPAA compliant and we will use reasonable means to protect the security and confidentiality of sessions that take place. However, Frederick SLP cannot guarantee the privacy and security of the patient’s internet connection. It is your duty to protect your internet against access and connection. Frederick SLP will not be liable for anyone observing the sessions on your end if you choose to participate while in a public setting. You may revoke your authorization to participate in tele-practice sessions with you by email at any time by written consent.

Signature

Date / Time

Date

Time

Billing and Insurance

Frederick SLP will bill your insurance company for each session and your coverage will be based on your speech therapy benefits.
You will still be responsible for your copay, coinsurance, or deductible.
New clients: Frederick SLP will check your speech therapy benefit before you begin services and will give you the information provided to us by your insurance company. Please fill out the entire section of your insurance information on the intake forms or send us a picture of your insurance card via email so we can ensure accuracy. Billing:

Clients will have the option of keeping a credit card on file – this will give us consent to charge your credit card for your copay after your session is completed.
If you choose not to keep a card on file – clients will receive a phone call from our front office staff requesting payment.
If there is a balance due on your account – clients will receive a monthly bill via mail and/or email.

FAQ

Do I need to be present for my child’s session?
Parent will need to be present during session in order to assist child with technology issues that may arise and maintaining attention to the task as clinician will not be able to redirect as typical during session
How should the environment be arranged?
Your child will need access to a device for their session (laptop, Chromebook, tablet or phone). Limit distractions in the environment as much as possible including siblings, TV etc. For additional information, contact your child’s individual therapist regarding needs for your particular child.
Where will my speech therapist be during my sessions?
Your therapist maybe in the clinic or at their home. If your therapist is in their home, they will be in a room away from other individuals who may be present in the home setting.
How will I schedule my sessions?
Please schedule your sessions by emailing your therapist./li>
What will the session look like?
Based on your child’s current goals, the therapist will work with you to arrange the environment or email you materials if needed. The therapist may pull up games or activities to use with your child on screen share. The therapist may also have the child interact with items in the environment as appropriate. This type of therapy may look different than your normal session, but do not fear all activities are geared towards continuing to target your child’s goals.
What app or technology will I need?
At this time, our therapist will be using the ZOOM platform. You will receive an email link from your therapist in order to join the meeting. You can use Zoom on a tablet, smartphone or a computer.
How will I pay for my sessions?
Please see the previous letter from our office manager.

Frederick SLP Case History Form

Please fill out the following information to the best of your ability. If you are unsure of an answer please leave it blank.

Identifying and Family Information:

Child’s Name:

Date

Nickname:

Gender:

Mother’s Name:

Father’s Name:

Doctor’s Name:

Phone

Individual filling out this form:

Child Lives with (Check One):

Birth Parents
Adoptive Parents
Foster Parents
Parent and Step Parent
Parent
Other

Other Children in the Family:

Name

Age

Sex

Grade

Speech/ Hearing Problems

Is there any languages other than English spoken in the home:

If yes, which ones?

Does the child speak the language?

Does the child understand the language?

Who speaks the language?

Which language does the child prefer to speak at home?

Birth - Medical History

Was there anything unusual about the pregnancy or birth?

If so, please describe.

How many weeks/ Months was the pregnancy:

How old was the mother when the child was born:

Did the child go home with the parents from the hospital:

It the child stayed in the hospital, please describe why and for how long:

Has your child had any of the following:

Adenoidectomy
Encephalitis
Seizures
Breathing difficulties
Head injury
Colds
Thumb/finger sucking
Flu
High fevers
Sleeping difficulties
Tonsillectomy

List any allergies your child has:

Has your child had an ear infection:

How Many:

List any concerns with Vision/ Hearing:

Other injuries/surgeries/Diagnoses:

Please list any medications or vitamins the child takes regularly:

When did your child say their first word: Walked:

Speech- Language- Hearing

Has your child’s speech ever been evaluated:

If so, by whom and when:

Have any family members previously received speech therapy:

Single Line Text

Does your child receive other services (PT, OT, ABA, counseling)

If so, how often and where:

Has your child received services through Infants and toddlers/ Child Find or the school system:

If so what are their goals:

What percentage of the time are you able to understand your child:

Do other people have a difficult time understanding your child:

What sounds is your child having a hard time producing:

Does your child get frustrated when they’re not understood

How does your child interact with others (shy, Aggressive, Inflexible, etc.)

Do you have concerns about your child’s social skills or ability to make friends:

What toys does your child like to play with:

Does your child:

Repeat sounds, words or phrases over and over?
Second Can they Understand what you are saying? Choice
Retrieve/point to common objects upon request (ball, cup, shoe)?
Follow simple directions (“shut the door” or “get your shoes”)?
Respond correctly to yes/ no questions?
Respond correctly to who/what/where/when/why questions?

Your Child currently communicates using:

Body language
Sounds (vowels, grunting)
Words (shoe, doggy, up)
2 to 4 word sentences
Sentences longer then for words
Other:

Behavioral Characteristics:

Cooperative
Attentive
Restless
Willing to try new activities
Poor eye contact
Easily distracted/short attention
Destructive/aggressive
Withdrawn
Separation difficulties
Easily frustrated
Impulsive
Inappropriate behavior
Self abusive behavior
Stubborn
Plays alone for a reasonable length of time

Feeding - If you do not have concerns with your child’s eating, please skip ahead

What is your main concern in regards to your child eating:

How does your child do with eating:

Would you describe your child as a picky eater:

What foods does your child eat:

What food does your child not like:

Does your child dislike specific food textures:

If so please describe:

Describe what meal time looks like:

Does your child feed themselves

What does your child usually drink from:

Cup
Straw
Sippy Cup (Type: )
Bottle (Type: )

School History

Does the child attend Daycare/School:

Days per week:

If your child attends school, please answer the following:

Name of school:

Teachers Name & Grade:

What type of classroom setting does your child participate in:

General education classroom
Special Education
Specialized school

Does your child have and IEP or 504:

Do we have a copy

What are your strengths and or best subjects:

Is your child having any difficulties with any subjects:

Does your child receive help with any subjects:

Has your child repeated a grade:

Additional comments relating to your child speech needs:

ATTENDANCE AND CANCELLATION POLICY

Revised and Effective January 1, 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.

Late arrival:

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.

Please print name of patient

Date

Signature

Checkboxes

First Choice
Second Choice
Third Choice

Welcome!

APPOINTMENT REMINDER

CARE PHYSICIAN

INSURANCE INFORMATION

EMERGENCY CONTACT INFORMATION:

TREATMENT AUTHORIZATION

Payment Policy:

Account Accumulation:

Past Due Accounts:

Payment Plans:

Credit Card Authorization Form

HIPPA Compliance Form - Telehealth

Billing and Insurance

FAQ

Frederick SLP Case History Form

Please fill out the following information to the best of your ability. If you are unsure of an answer please leave it blank.

Identifying and Family Information:

Other Children in the Family:

Birth - Medical History

Speech- Language- Hearing

Feeding - If you do not have concerns with your child’s eating, please skip ahead

School History

If your child attends school, please answer the following:

ATTENDANCE AND CANCELLATION POLICY

Cancellations/No Shows -

Late arrival:

MY SIGNATURE BELOW INDICATES THAT I HAVE READ THE ABOVE POLICY, UNDERSTAND AND ACCEPT THE TERMS AND CONDITIONS.

Frederick-slp

Contact Us

(301) 668-1852

frederickslp.newpatient@gmail.com

Fax # (301) 668-1854

Company

Welcome!

APPOINTMENT REMINDER

CARE PHYSICIAN

INSURANCE INFORMATION

EMERGENCY CONTACT INFORMATION:

TREATMENT AUTHORIZATION

Payment Policy:

Account Accumulation:

Past Due Accounts:

Payment Plans:

Credit Card Authorization Form

HIPPA Compliance Form - Telehealth

Billing and Insurance

FAQ

Frederick SLP Case History Form

Please fill out the following information to the best of your ability. If you are unsure of an answer please leave it blank.

Identifying and Family Information:

Other Children in the Family:

Birth - Medical History

Speech- Language- Hearing

Feeding - **If you do not have concerns with your child’s eating, please skip ahead**

School History

If your child attends school, please answer the following:

ATTENDANCE AND CANCELLATION POLICY

Cancellations/No Shows -

Late arrival:

MY SIGNATURE BELOW INDICATES THAT I HAVE READ THE ABOVE POLICY, UNDERSTAND AND ACCEPT THE TERMS AND CONDITIONS.

Feeding - If you do not have concerns with your child’s eating, please skip ahead