“Your Home for Family-Centered Services”
New Family Packet
7540 Sawmill Parkway Suite A-2
Powell, Ohio 43065
(614) 973-9755
Cornerstonespeechtherapy.com
“Your Home for Family-Centered Services”
Welcome to Cornerstone Speech Therapy!
At Cornerstone Speech Therapy, we want to give your child a solid foundation, or
cornerstone, for development. This starts with involving you in your child’s learning. We are a
private practice of dedicated professionals who love working with children and families in the
home or our “home-like” office setting. We believe that children learn best through
opportunities within their daily routines and activities. From experience, we have found that
significant progress can be made when you are an active participant in the therapy process.
Our effective interventions are focused on the priorities your family has for your child and we
include you every step of the way. You are the expert on your child and we are excited to
partner with you.
If at any time, you would like something to change or if we are not providing the
services you expect, please let us know. This is a partnership and we want you to feel
comfortable communicating your priorities with us. Also, we want you to stay informed about
the latest research and resources in your community. Please stay connected with us at
cornerstonespeechtherapy.com and follow us on Facebook (search Cornerstone Speech
Therapy LLC) and Twitter (search CornerstoneST).
Thank you for choosing Cornerstone Speech Therapy. We look forward to serving your
child and your family.
Sincerely,
Janelle Pickens, MS, CCC-SLP
Speech-Language Pathologist/Owner
7540 Sawmill Parkway, Suite A-2, Powell, OH 43065
Office: (614)973-9755 • Fax: (740)917-5703
cornerstonespeechtherapy.com
“Your Home for Family-Centered Services”
Why Family-Centered Services?
Cornerstone Speech Therapy prides itself on an approach that is different from
many other providers. Why have we chosen this approach?
Not only does it just make sense to provide services that include and
inform families, but our approach is also backed by research.
We believe, and research shows, that the family unit is the most important and
influential part of a child’s development. Children learn the most from the people who are
closest to them. Your family has cared for your child since the very beginning and, through this
time together, you have become a true expert on your child. Your family knows and
understands what makes your child happy, sad, uncomfortable, excited, scared, and sometimes
even grumpy. You know your child's strengths and interests and you understand their
challenges. Because of the respect we have for your family's knowledge and experience,
Cornerstone partners with you to understand these special qualities and develop strategies that
address your family's priorities for your child.
Family-centered services also empower your family to incorporate intervention
strategies into your child’s daily routines. Intervention is not something that only happens once
a week during a speech therapy session, but should occur multiple times per day through
activities in which your child naturally participates. Your family is already doing things that can
be powerful learning opportunities. These activities can be anything from folding laundry to
wrestling with daddy and are unique to your family. Because of our approach, your family will
not have a designated time in your day to “work on speech” because it will naturally be
embedded in each and every activity you experience with your child.
A visit with Cornerstone may also look different from a traditional therapy session.
Because of our emphasis on family involvement, your family is asked to participate and learn
how to best help your child. Our visits take place either in your home or in our "home-like"
office location. We use a coaching approach as we work with your family. We ask questions,
model strategies and allow your family the opportunity to try some things while we are there.
We want you to have the confidence and competence to support your child’s development on
your own.
At Cornerstone Speech Therapy, your family is at the very heart of what we do. While we may
be experts on speech and language development, we know that you are the expert on your
child. Cornerstone truly is “your home for family-centered services".
7540 Sawmill Parkway, Suite A-2, Powell, OH 43065
Office: (614)973-9755 • Fax: (740)917-5703
cornerstonespeechtherapy.com
“Your Home for Family-Centered Services”
Family and Child Information
Child’s Name: __ ___________________________
Address: ___
Date of Birth: ____________
________________________________________________________
Mother’s Name: __________________________ Occupation (optional):__
Home Phone: __
_____________ Cell Phone: __
Father’s Name: ____
Home Phone: ___
___
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____________ Email: ____ _________
_______________________Occupation (optional): _
____________ Cell Phone: __________
__________
____ Email: ____ _________
Would you like to sign up for our quarterly newsletter? Yes ______ No ______
Pediatrician: _______________________
_______ Phone: ___________
__________
Names/Ages of Siblings: _____
___________________________________________
How did you hear about us? ___
___________________________________________
Please tell us why you chose Cornerstone Speech Therapy: __
____________
_______________________
______________________________________________________
What are your family’s priorities for your child? __
____________
_______________________________
_____________________________________________________
__________________
____________ ____________________________________
Please describe your child’s current communication abilities: ________________
____________________________
________________
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______________________________________
__________________________________________________
Have you worked with any other speech-language pathologists or had a speech-language
evaluation completed recently? What were the recommendations? We would appreciate any
copies of reports you can give us. _______________________________________
____
_________
_________________________________________________________
7540 Sawmill Parkway, Suite A-2, Powell, OH 43065
Office: (614)973-9755 • Fax: (740)917-5703
cornerstonespeechtherapy.com
“Your Home for Family-Centered Services”
What other professionals have worked with or are working with your child? (service
coordinators, early intervention specialists, physicians, psychologists, audiologists, occupational
therapists, physical therapists, special education teachers, etc.)
________
_________________________________________________
_________________
_________________________________________________
_________________
Does your child have a significant medical history or medical condition you would like to share
with us? Any known vision or hearing difficulties? ___________
____________________
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________________________________________________________
Describe your child’s development. Did he/she meet developmental milestones on time?_____
___________________________________________________________
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If your child has an existing IFSP or IEP, what goals from these plans would you like us to
address? We would appreciate a copy of this plan for our records.
_________________________________________________________
________
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_______________________________________________________________
Tell us about your child. What are his or her special interests? Describe his or her personality.
____
_______
_____________________________________________________________
__________________________________________________________
Please describe the strategies you have tried with your child. Were they successful? Why or
why not? _________________
_____________________________________________
___________
_______________
_______________________________________________________
___________________________________________________
What do you expect from our visits? How do you want them to look?
_________________________
_________________________________________
7540 Sawmill Parkway, Suite A-2, Powell, OH 43065
Office: (614)973-9755 • Fax: (740)917-5703
cornerstonespeechtherapy.com
“Your Home for Family-Centered Services”
Please provide any additional information that we may need to best serve your child and your
family: __
__________________________________________________________
________
_________
__________________________________________________________
_________________________________________________________
Besides just speech and language services, what do you need as a family to better support your
child overall? __________________________________________________________________
__________
________________________________________________________
Consent for Treatment
I hereby give my permission to the staff of Cornerstone Speech Therapy to carry-out all
necessary diagnostic, assessment, and treatment services that will address the needs of the
above named client.
_________________ _______________
Parent or Guardian Signature
__
7540 Sawmill Parkway, Suite A-2, Powell, OH 43065
Office: (614)973-9755 • Fax: (740)917-5703
cornerstonespeechtherapy.com
_
Date
“Your Home for Family-Centered Services”
Family and Provider Agreement
At Cornerstone Speech Therapy, our goal is to partner with you to help your child
succeed. We value your ideas and contributions and believe that your child can make better
progress when you are actively involved.
So that we can provide meaningful services that meet the unique needs of your child,
please respect the following guidelines during our visits:
1.
2.
3.
4.
5.
6.
Be present and participate with us and your child.
Communicate your families’ priorities for your child.
Share with us your child’s strengths and interests.
Tell us about what you have practiced during the week.
Develop a plan with us at the end of each visit.
Keep distractions to a minimum (ex. television, phone use, etc.)
We agree to do the following:
1.
2.
3.
4.
5.
Capitalize on your child’s interests and family activities.
Develop strategies that address your priorities.
Provide information on speech and language development.
Demonstrate and practice evidence-based techniques.
As much as possible, use toys and other items that you already have in the home to
promote immediate carry-over.
6. Provide written summaries at the end of each visit and periodic progress reports.
7. Communicate with other professionals and caregivers in your child’s life when
appropriate.
Thank you for the opportunity to serve your child and your family. Please speak with your
provider with any questions or concerns or contact our Family Service Coordinator, Jennifer
Pierson, at (614) 973-9755. Also, feel free to complete our on-line survey at any time.
_______________________________
Parent Signature
_____________
Date
7540 Sawmill Parkway, Suite A-2, Powell, OH 43065
Office: (614)973-9755 • Fax: (740)917-5703
cornerstonespeechtherapy.com
“Your Home for Family-Centered Services”
Agreement To Pay
Cornerstone accepts a variety of funding sources, including some insurance plans. Some families choose
to pay privately. Cornerstone will make every effort to obtain payment on your behalf. Please read the
information below so you better understand the payment terms required.
Insurance Company / Funding Source:
________________________________
____ We are in-network with your insurance company.
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You are responsible for any co pays, deductibles or non-covered service on your plan.
You are responsible for payment if your insurance company does not respond with-in 90 days of
claim submission.
You are responsible for payment in full if your claim is denied as a non-covered service.
You are responsible for obtaining physician prescriptions and referrals required by your
insurance company.
____ We are out-of-network with your insurance company.
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Cornerstone Speech Therapy will bill your insurance on your behalf.
You are responsible for payment in full 30 days from invoice. Any reimbursement will be sent
directly to you from your insurance company.
Your insurance company may not correspond with us. You must let Cornerstone Staff know if
your insurance company needs additional information.
Cornerstone can automatically debit your credit or debit card for easier payment options.
____ Private Pay Client.
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Payment is due 30 days from Invoice date.
Cornerstone can automatically debit your credit or debit card for easier payment options.
_____ Alternative Funding Source.
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You are responsible for signing any required documents in a timely manner.
You must notify Cornerstone immediately of any change in your funding status. You are
ultimately responsible to pay for any service rendered without proper authorization for the
funding source.
Please contact Cornerstone Speech Therapy with any questions regarding your funding. We are happy to
assist you to determine the best payment option based on your family’s needs and eligibility.
_________________ _______________
Parent or Guardian Signature
__
7540 Sawmill Parkway, Suite A-2, Powell, OH 43065
Office: (614)973-9755 • Fax: (740)917-5703
cornerstonespeechtherapy.com
_
Date
“Your Home for Family-Centered Services”
Assignment of Benefits
I authorize my third-party payer (insurance or other payers) to assign benefits to Cornerstone
Speech Therapy. I authorize Cornerstone Speech Therapy to file claims on my behalf and
accept assignment of benefits.
Check Return Policy
There will be a $25.00 fee for each returned check.
Past Due Accounts
Clients with an outstanding balance may have services placed on hold until arrangements can
be made to meet the financial obligations. After 60 days, outstanding balances may be charged
a 1.5% interest fee and be turned over to a collections agency.
Ohio Medicaid Waiver Agreement
I understand Cornerstone Speech Therapy is not a provider for the Ohio Medicaid Program. I
understand that by choosing Cornerstone Speech Therapy, I am waiving my ability to utilize
Ohio Medicaid benefits for any services rendered at Cornerstone Speech Therapy.
____________________________________
Parent / Legal Guardian Signature
_________
Date
7540 Sawmill Parkway, Suite A-2, Powell, OH 43065
Office: (614)973-9755 • Fax: (740)917-5703
cornerstonespeechtherapy.com
“Your Home for Family-Centered Services”
Auto Debit Agreement for Cornerstone Speech Therapy
I __________________________hereby authorize Cornerstone Speech Therapy to debit my card for ongoing speech therapy sessions in the amount of $____________.
Visa / MC / Discover / Amex – please circle one
Card Number ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Expiration Date ___ ___ / ___ ___
CV code ___ ___ ___ - back of your card
Client Name: _______________________________________ DOB: ______________________
___________________________________________________________ ____________________
Cardholder Signature Date
7540 Sawmill Parkway, Suite A-2, Powell, OH 43065
Office: (614)973-9755 • Fax: (740)917-5703
cornerstonespeechtherapy.com
“Your Home for Family-Centered Services”
Attendance Policy
Regular attendance is important for your child and family’s success and we will make every
effort to schedule appointments that meet your needs. In order to provide the best services
possible for all of the families in our practice, we ask that you follow the attendance policy
outlined below:
1. Cancellations: Please notify us at least 24 hours in advance to cancel your appointment.
2. Missed appointments: If there is a pattern of frequent cancellations or no shows, our
services may be discontinued or put on hold at the discretion of the management.
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.
4. Clinician Cancellations: If your therapist is not able to attend your appointment, you will
be contacted as soon as possible. Please be sure that we know the best way to reach
you. Every effort will be made to reschedule your appointment in a timely manner.
To cancel an appointment, please contact your therapist ________________________:
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Phone _________________________
E-mail _________________________
□ I have read and understand the policy listed above.
________
Patient Name
__
_____________________________________________
Parent/Guardian Signature
_____________________
Date
7540 Sawmill Parkway, Suite A-2, Powell, OH 43065
Office: (614)973-9755 • Fax: (740)917-5703
cornerstonespeechtherapy.com
“Your Home for Family-Centered Services”
Notice of Privacy Practices
As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996
(HIPAA)
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU and YOUR CHILD (as a patient of this practice) MAY BE
USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
OUR COMMITMENT TO YOUR PRIVACY
Cornerstone Speech Therapy is dedicated to maintaining the privacy of your individually identifiable health information (IIHI).
In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are
required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide
you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your IIHI. By
federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.
We realize that these laws are complicated, but we must provide you with the following important information:
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How we may use and disclose your IIHI
Your privacy rights in regard to your IIHI
Our obligations concerning the use and disclosure of your IIHI
The terms of this notice apply to all records containing your IIHI that are created or retained by our practice. We reserve the
right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of
your records that our practice has created or maintained in the past, and for any of your records that we may create or
maintain in the future. Our practice will post a copy of our current Notice in our office in a visible location at all times, and
you may request a copy of our most current Notice at any time.
IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
Practice Administrator, PO Box 16092, Columbus, OH 43016
Cornerstone Speech Therapy may use and disclose your IIHI in the following ways:
1. Treatment. Our practice may use your IIHI to treat you. For example, we may ask you to have laboratory tests (such as
audiology or developmental evaluations), and we may use the results to help us reach a diagnosis. Many of the people who
work for our practice – including, but not limited to, our speech pathologists – may use or disclose your IIHI in order to treat
you or to assist others in your treatment. Additionally, we may disclose your IIHI to others who may assist in your care, such as
your spouse, children or parents.
2. Payment. Our practice may use and disclose your IIHI in order to bill and collect payment for the services and items you may
receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what
range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will
cover, or pay for, your treatment. We also may use and disclose your IIHI to obtain payment from third parties that may be
responsible for such costs, such as family members. Also, we may use your IIHI to bill you directly for services and items.
7540 Sawmill Parkway, Suite A-2, Powell, OH 43065
Office: (614)973-9755 • Fax: (740)917-5703
cornerstonespeechtherapy.com
“Your Home for Family-Centered Services”
3. Health Care Operations. Our practice may use and disclose your IIHI to operate our business. As examples of the ways in
which we may use and disclose your information for our operations, our practice may use your IIHI to evaluate the quality of
care you received from us, or to conduct cost-management and business planning activities for our practice.
4. Appointment Reminders. Our practice may use and disclose your IIHI to contact you and remind you of an appointment.
5. Treatment Options. Our practice may use and disclose your IIHI to inform you of potential treatment options or
alternatives.
6. Release of Information to Family/Friends. Our practice may release your IIHI to a friend or family member that is involved
in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child to
the office for a treatment session. In this example, the babysitter may have access to this child’s medical information.
7. Disclosures Required By Law. Our practice will use and disclose your IIHI when we are required to do so by federal, state or
local law.
USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL CIRCUMSTANCES
The following categories describe unique scenarios in which we may use or disclose your identifiable health information:
1. Public Health Risks. Our practice may disclose your IIHI to public health authorities that are authorized by law to collect
information for the purpose of:
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maintaining vital records, such as births and deaths
reporting child abuse or neglect
preventing or controlling disease, injury or disability
notifying a person regarding potential exposure to a communicable disease
notifying a person regarding a potential risk for spreading or contracting a disease or condition
reporting reactions to drugs or problems with products or devices
notifying individuals if a product or device they may be using has been recalled
notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an
adult patient (including domestic violence); however, we will only disclose this information if the patient agrees
or we are required or authorized by law to disclose this information
notifying your employer under limited circumstances related primarily to workplace injury or illness or medical
surveillance.
2. Health Oversight Activities. Our practice may disclose your IIHI to a health oversight agency for activities authorized by law.
Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil,
administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government
programs, compliance with civil rights laws and the health care system in general.
3. Lawsuits and Similar Proceedings. Our practice may use and disclose your IIHI in response to a court or administrative
order, if you are involved in a lawsuit or similar proceeding. We also may disclose your IIHI in response to a discovery request,
subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of
the request or to obtain an order protecting the information the party has requested.
4. Law Enforcement. We may release IIHI if asked to do so by a law enforcement official:
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Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement
Concerning a death we believe has resulted from criminal conduct
7540 Sawmill Parkway, Suite A-2, Powell, OH 43065
Office: (614)973-9755 • Fax: (740)917-5703
cornerstonespeechtherapy.com
“Your Home for Family-Centered Services”
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Regarding criminal conduct at our offices
In response to a warrant, summons, court order, subpoena or similar legal process
To identify/locate a suspect, material witness, fugitive or missing person
In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or
location of the perpetrator).
5. Serious Threats to Health or Safety. Our practice may use and disclose your IIHI when necessary to reduce or prevent a
serious threat to your health and safety or the health and safety of another individual or the public. Under these
circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
6. Military. Our practice may disclose your IIHI if you are a member of U.S. or foreign military forces (including veterans) and if
required by the appropriate authorities.
7. National Security. Our practice may disclose your IIHI to federal officials for intelligence and national security activities
authorized by law. We also may disclose your IIHI to federal officials in order to protect the President, other officials or foreign
heads of state, or to conduct investigations.
8. Inmates. Our practice may disclose your IIHI to correctional institutions or law enforcement officials if you are an inmate or
under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to
provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety
or the health and safety of other individuals.
9. Workers’ Compensation. Our practice may release your IIHI for workers’ compensation and similar programs.
E. YOUR RIGHTS REGARDING YOUR IIHI: You have the following rights regarding the IIHI that we maintain about you:
1. Confidential Communications. You have the right to request that our practice communicate with you about your health and
related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather
than work. In order to request a type of confidential communication, you must make a written request to the Practice
Administrator specifying the requested method of contact, or the location where you wish to be contacted. Our practice will
accommodate reasonable requests. You do not need to give a reason for your request.
2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your IIHI for treatment,
payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your IIHI to
only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not
required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required
by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or
disclosure of your IIHI, you must make your request in writing to the Practice Administrator and include:
(a) the information you wish restricted;
(b) whether you are requesting to limit our practice’s use, disclosure or both; and
(c) to whom you want the limits to apply.
3. Inspection and Copies. You have the right to inspect and obtain a copy of the IIHI that may be used to make decisions about
you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your
request in writing to Practice Administrator in order to inspect and/or obtain a copy of your IIHI. Our practice may charge a fee
for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to
inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed
health care professional chosen by us will conduct reviews.
7540 Sawmill Parkway, Suite A-2, Powell, OH 43065
Office: (614)973-9755 • Fax: (740)917-5703
cornerstonespeechtherapy.com
“Your Home for Family-Centered Services”
4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may
request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request
must be made in writing and submitted to the Practice Administrator. You must provide us with a reason that supports your
request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your
request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and
complete; (b) not part of the IIHI kept by or for the practice; (c) not part of the IIHI which you would be permitted to inspect
and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to
amend the information.
5. Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures.” An “accounting of
disclosures” is a list of certain non-routine disclosures our practice has made of your IIHI for non-treatment or operations
purposes. Use of your IIHI as part of the routine patient care in our practice is not required to be documented. For example,
the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In
order to obtain an accounting of disclosures, you must submit your request in writing to the Practice Administrator. All requests
for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of
disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of
charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of
the costs involved with additional requests, and you may withdraw your request before you incur any costs.
6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may
ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact the Practice Administrator.
7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or
with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact the Practice
Administrator. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
8. Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for
uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us
regarding the use and disclosure of your IIHI may be revoked at any time in writing. After you revoke your authorization, we will
no longer use or disclose your IIHI for the reasons described in the authorization. Please note, we are required to retain records
of your care.
If you have any questions about this notice, please contact the Practice Administrator, P.O. Box 16092, Columbus, OH 43216.
Acknowledgement of Receipt of the Notice of Privacy Practices
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Client Name
_______________________
Date of Birth
I have been provided a copy of Cornerstone Speech Therapy’s Notice of Privacy Practices for review. I
understand I may request a written copy of the Privacy Practices at any time.
___________________________
Signature of Client/Guardian
________________________
Date
7540 Sawmill Parkway, Suite A-2, Powell, OH 43065
Office: (614)973-9755 • Fax: (740)917-5703
cornerstonespeechtherapy.com