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Intake Form in English
Intake Form in English
INTAKE FORMS FOR NEW CLIENTS
8848 RED OAK BLVD. SUITE AA CHARLOTTE, NC 28217 TEL: (980) 422-5887 / FAX: (980) 225-0025
Cell Phone Carrier:
P.O. box/ Home/ Apt #:
Other family members seen at Speech Tactics:
(Please give your insurance card to the receptionist.)
DAYCARE / SCHOOL INFORMATION
Does the child have an IEP?
May we request a copy of the client’s IEP from the school?
Primary Pediatrician’s Name:
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address):
Relationship to patient and phone number:
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Speech Tactics or insurance company to release any information required to process my claims
Thank you for choosing Speech Tactics for your child’s care. The policies written below are designed to improve our ability to see all of our clients and to provide complete, consistent treatment for your child. We hope these policies will improve our overall service to our families. Since continuity of care is important to maximize the outcomes of your child’s therapy,
we use the following guidelines for your appointments:
Therapists often are not able to wait more than 15 minutes for a late appointment.
Please notify your therapist as soon as you know you are going to be late.
Because of scheduling constraints, late arrivals may not be able to be seen, and if seen, the session will end at the regularly scheduled time. If you are late
and your therapist needs to see your child for a shorter amount of time, you will be charged for the entire scheduled session.
2. 24-hour, or more, advance notice for all cancelled appointments is
If you need to cancel your child’s appointment, our Clinic requires that you cancel 24 hours in advance of the scheduled appointment time. You will be charged $25.00 except in an emergency situation for the scheduled therapy appointment which was missed.
If you have
3 or more
cancellations within a
or you miss more than ½ of your scheduled appointments within the quarter, you may lose your standing appointment time slot. Additionally, your child may be placed on hold for therapy. You will be notified by phone or letter should this occur. If removal from the schedule should occur, in order to be put back on the schedule, a mandatory meeting, or telephone conference, between the family and Clinic Director will be required.
A cancellation at the time of the courtesy/reminder call by the Clinic Coordinator does not constitute a 24-hour notification.
5. “NO-SHOWS” ARE UNACCEPTABLE.
If you do not attend your scheduled appointment and you have not called to give any type of notification that the session was going to be missed, you will be considered to be a “No Show” for that appointment. Additionally, a 2
5.00 penalty fee
will be assessed. If you have two “No Shows” for scheduled appointments, your child’s therapy will be put on hold and you will be notified (if within a two-month period, immediate and irrevocable removal from the schedule will occur). Please note that a telephone call after the appointment does not constitute notification and will be considered a “no-show”.
Please sign below. By signing you indicate that you understand the terms outlined above. Thank you for your commitment to your child’s therapy
SICK CHILD POLICY
bring a sick child to therapy. If your child shows signs of illness, described below, or is unable to participate in a therapy session, he/she will be sent home. Sick children will expose other children, staff members, and therapists who they come in contact with. These people can in turn expose the other children. If other children become ill, due to exposure to your sick child, either because he/she was sick, or he/she participated in therapy before full recovery, other parents will be unnecessarily inconvenienced by their child becoming sick. Because this is disruptive to other children and their families, your cooperation on this issue is extremely important. Remember, sick children want care from their parents in the comfort of their own homes.
If your child is unable to participate in the typical therapy activities then your child should stay home.
Every effort should be taken to reduce the spread of illness, by encouraging hand washing and other sanitary practices.
For the benefit of our staff, therapists, and other children in our care, a sick child will not be permitted to return to care for 24 hours after condition has returned to normal. Children with diagnosed infections may return at least 48 hours (depending upon the illness) after they have received the first dose of an antibiotic. If a child receives an antibiotic for an ear infection, he/she may attend therapies if he/she has been free of other symptoms (mentioned below) for at least 24 hours. If you are not sure about whether to bring your child to therapy, please call our office. Allergy related symptoms, and non-communicable illnesses do not require exclusion if you have a note from your doctor.
Symptoms requiring your child to not participate in his/her therapies:
▪ Fever: Fever is defined as having a temperature of 100°F or higher taken under the arm, 101°F taken orally, or 102°F taken rectally. For children 4 months or younger, the lower rectal temperature of 101°F is considered a fever threshold; (a child needs to be fever free for a m inimum of 24 hours before returning to therapy, that means the child is fever free without the aid of Tylenol®, or any other fever reducing substance.)
▪ Fever AND sore throat, rash, vomiting, diarrhea, earache, irritability, or confusion.
▪ Diarrhea: runny, watery, bloody stools, or 2 or more loose stools within last 4 hours.
▪ Vomiting: 2 or more times in a 24 hour period. (Note: please do not bring your child if they have vomited in the night)
▪ Breathing trouble, sore throat, swollen glands, loss of voice, hacking or continuous coughing.
▪ Runny nose (other than clear), draining eyes or ears.
▪ Frequent scratching of body or scalp, lice, rash, or any other spots that resemble childhood diseases, including ringworm.
▪ Child is irritable, continuously crying, or requires more attention than we can provide without hurting the health, safety or well-being of the other children in our care.
If you have questions or concerns about your child’s health, please contact his/her pediatrician.
By signing below, I acknowledge that I have read, understand, and agree to abide by the “Sick Child Policy”. This includes understanding that my child may be sent home if he/she demonstrates any of the sickness signs/symptoms on a scheduled therapy day
Signature of Patient or Personal Representative
Printed Name of Patient or Personal Authority
Description of Personal Representative’s Authority
NOTIFICATION OF SERVICE PROVIDER
Our Speech Tactics practice consist of highly trained and competent speech pathologist, speech-language pathology assistants, occupational therapist, and occupational therapy assistants. Your child will be serviced by a certified: SLP, SLP-A, OT, COTA
I consent to these services
Acknowledgment That You Have Received Our HIPAA Privacy Notice
Speech Tactics LLC is required by law to keep your health information safe. This information may include: Notes from your doctor, teacher, or other health care provider, evaluation reports, therapy notes, assessment results, progress notes, communication notes, and 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. It also tells you how you can look at and comment on your information. This can be provided to you via email as well, if you choose. All clients have direct access to the HIPAA Privacy Notice on our Website. Please initial to indicate that you received and/or know where to find the HIPAA notice:
CLIENT FINANCIAL RESPONSIBILITY FORM
Thank you for choosing Speech Tactics for your pediatric and adult communication needs. We are committed to providing you with the highest quality care. We ask that you read and sign this form to acknowledge your understanding of our client financial responsibility policies.
Client Financial Responsibilities
▪ The Client (or Client’s guardian, if a minor) is ultimately responsible for the payment for treatment and care. ▪ We will bill your insurance for you. However, the client is required to provide the most correct and updated information regarding insurance.
▪ Clients are responsible for payment of copays, coinsurance, deductibles and all other Procedures or treatment not covered by their insurance plan.
▪ Copays are due at the time of service.
▪ Coinsurance, deductibles and non-covered items are due 30 days from receipt of billing.
▪ Clients may incur, and are responsible for payment of additional charges, if applicable
By my signature below, I hereby authorize assignment of financial benefits directly to Speech Tactics and any associated healthcare entities for services rendered as allowable under standard third party contracts. I understand that I am financially responsible for charges not covered by this assignment.
Your signature below verifies that you understand the information given above
Print Patient’s Name
Patient or Parent/Guardian Print Name and Signature
Relationship to Patient
CONSENT FOR PARENT EDUCATION
We ask that you read and sign this form in regard to HIPAA (Health Insurance Portability and Accountability Act).
Parent Education is a key component for your child making progress with his/her therapy goals. Parent education can be provided before, during, and after your child's therapy session(s) and our goal is to provide you with timely information to ensure your child's progress. It is important to understand that any conversations you have with your child's therapist in an open area, such as the waiting room, can be overheard by other parents.
Please select your preferred option and sign below.
My child's parent education can be conducted in an open area, such as the waiting room. By signing below, I understand the conversation with my child's therapist can be overheard by others. Your signature is required by the Federal HIPAA laws, indicating that you have read, understood and are in agreement with our parent education occurring in an open area.
My child's parent education must be conducted in a private area, to ensure the conversation with my child's therapist is not overheard by others. Your signature is required by the Federal HIPAA laws, indicating all parent education should occur in a private area.
Patient or Guardian:
Please read below to find your HIPAA Privacy Rights and our Sick Policy: