Contract for Speech and Language Services

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Contract for Speech Language Services

Welcome to The Southfield Center for Development. Please take a moment to familiarize yourself with the office policies and procedures that are outlined in this contract. If there are any items that are unclear to you, please ask for clarification. When you sign this document, it also will represent an agreement between us. You may revoke this agreement in writing at any time.

Speech and Language Therapy Services

Speech and Language therapy involves a commitment of time, money, and energy. For therapy to be optimal, it is important that the child and family take responsibility for carry over at home of learned strategies and/ or exercises provided by the speech language pathologist. Generalizing skills learned in therapy to home and school is the key to success. Throughout the therapeutic process feel free to talk to the clinician about any question you have questions about the procedures, homework, and progress.

Therapy sessions are typically 45-60minutes in length and occur weekly. We will determine together the length and schedule of sessions that will best meet your child’ s needs. Once an appointment hour is scheduled, you will be expected to pay for it at the time of service.

Professional Fees:

The hourly rate should be paid at the time of service. In addition, to weekly appointments, the clinician will charge, as applicable, for other professional services you may need. The clinician will prorate the hourly cost if the clinician works for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 10 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service as requested. If you become involved in legal proceedings that require the clinician’s participation, you will be expected to pay for all of the professional time.

Cancellation Policy:

Cancellations for scheduled therapy sessions must be given 24 hours in advance, as this time has been reserved for your child. The hourly session fee or a prorated amount depending on length of individual child’s session will be charged for all missed appointments or cancellations made the day of scheduled session. In the case of sudden illness or other emergency, we can discuss rescheduling missed appointments.

Illness Policy:

For the well-being and protection of all children being served at the Southfield Center for Development, please reschedule your child’s session if he or she has had a fever or other contagious illness such as strep throat or stomach flu within 24 hours of scheduled session. If your child is taking penicillin or antibiotics please make sure they have been on them for at least 24 hours before coming in for therapy.

Contacting Me:

During business hours, The Southfield Center staff can be reached at 203-202-7654. Due to the clinical work that we do, we are not often immediately available by telephone. When we are unavailable, our telephone is answered by a voice mail that we monitor frequently. We will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform us of some times when you will be available.

Confidentiality and Privacy:

The law protects the privacy of all communications between a client and a speech language pathologist. In most situations, The Southfield Center can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this agreement provides consent for those activities.

There are some exceptions to this policy. In child custody proceedings or other judicial proceedings in which emotional condition is a relevant factor, a judge may require us to release records. Further, if over the course of the evaluation, we uncover information that leads us to suspect that a child, an elderly person, or a disabled person is being abused, we must file a report with the appropriate state agency. If we believe that a person is threatening serious bodily harm to self or others, we are required by law to take appropriate actions. This may include notifying police, the potential victim(s), or arranging for hospitalization. These situations have rarely arisen in our experience. Should such a situation occur, we will make every effort to fully discuss it with you before taking any action.

Permission to Release/Exchange Information Between Southfield Center Practitioners

The Southfield Center for Development is a multidisciplinary child development center that provides diagnostic, therapeutic and educational services in a collaborative environment. Our clinical and administrative team is dedicated to helping children and adolescents achieve their full potential. The exchange of information between Southfield Center providers, including but not limited to psychologists, psychiatrists, social workers, marriage and family therapists, speech pathologists, occupational therapists, learning specialists, education advocates, nutritionists, and executive functions coaches (collectively “Providers”), is part of what allows us to provide the highest level of service to the children and families we serve.

By signing this contract, you authorize information release/exchange concerning your child (or yourself, if you are the client being seen, and are 18 years of age or older), among Southfield Center providers. You understand that this information may be used for the provision of services, exchange of treatment information, diagnosis, progress and historical data, and continuation of the provision of services. You also understand that it is your right to revoke consent at anytime, except to the extent information has been released, obtained, or exchanged as originally permitted.

Professional Records:

Parents please note, pursuant to federal guidelines, The Southfield Center keep protected health information about your child. This professional record includes your child’s clinical evaluations, a description of the ways in which your child’s speech and language issues impacts their life, their diagnosis, a treatment plan, progress notes towards those goals, treatment history, any previous evaluations or Individualized Education Plan that have been received from other providers, reports of any professional consultations, and any reports that have been sent to anyone, including reports to your insurance carrier.

Insurance Reimbursement:

If you have a health insurance policy, it will usually provide some coverage for speech, language and/or oral motor treatment. Accessing these benefits is often confusing and we will assist you in any way we can so that you can receive your entitled benefits. This will often include completing treatment request forms; participation in telephone review meetings; and assisting with the pre-authorization process. If the requested process involves more than 10 minutes of professional time, this time will be billed accordingly.

The Southfield Center provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of the fees. It is very important that you find out exactly what speech and language services your insurance policy covers.

You should carefully read the section in your insurance coverage booklet that describes speech and language services. If you have questions about the coverage, call your plan administrator.

You also should be aware that your contract with your health insurance company requires that The Southfield Center provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. I will provide you with a copy of any report I submit, if you request it. By signing this agreement, you agree that I can provide requested information to your carrier.

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