TIME FOR SPEECH
PEDIATRIC SPEECH THERAPY, LLC
NEW PATIENT REGISTRATION PACKET
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REQUIRED INFORMATION AT FIRST VISIT
New patient registration packet (this packet completed and signed
Proof of Insurance (originals or copies of front/back of card)
Co-Pay / Deductible (we accept: cash, checks, credit and debit cards)
 Any recent evaluations (speech, neurological, IEP)
Kathleen Morgan M.Ed., CCC-SLP / Amy Russell M.S., CCC-SLP
Anna Spilker MS.; CCC-SLP / Sarah Colle M.A., CCC-SLP / Maya Gamez M.A.; CCC-SLP
Contact Information
4050 Lake Otis Parkway Suite 105
Anchorage, Alaska 99508
Phone: 907-563-1167
Fax: 907-563-1169
www.timeforspeechak.com
Office Hours are 8:00 am – 6:00 pm Monday through Friday
9:00 am – 12:00 pm Saturday
Please submit your insurance information one week prior to your appointment, so that we may verify your insurance
benefits and notify you of your deductibles, co-pays, and non-covered services. All INITIAL appointments are verified 24
hours in advance with a reminder phone call, so please be sure to include a good contact number. We will summarize what
to expect at your visit at this time and we can answer any questions. If you have additional questions or would like to
make payment arrangements in advance, please call ahead of time.
ACKNOWLEDGEMENT OF RECEIPT
By signing below, I acknowledge and agree that a copy of Time for Speech Pediatric Speech Therapy, LLC (T4S) New
Patient Registration Packet has been made available to me, which includes:
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General Clinic Information
Financial Policies
Billing Policies
Payment Policies
Consent for Care
Patient Rights and Responsibilities
Clinic Expectations
Release of Information
HIPAA Policies & Procedures
Communication Policies
Web Site Policies
I understand that as a part of my child’s ongoing speech and language therapy, T4S receives, originates, maintains,
discloses and uses individually identifiable health information, including, but not limited to, health records and other
health information describing my health history, evaluation and test results, diagnosis, plan of care, therapy goals
and billing and health insurance information. I understand that T4S and its speech language pathologists and staff
may use this information to perform the following tasks: Diagnose my child’s speech and language delay, plan my
child’s treatment and care, communicate with other health and educational professionals concerning my child’s
care, document services for payment/reimbursement, conduct routine health care operations, such as quality
assurance.
T4S’s New Patient Registration Packet has been made available to me, including T4S’s Notice of Privacy Practices,
which fully explains the uses and disclosures that this practice will make with respect to my child’s identifiable health
information. I understand that I have the right to review this NOTICE before signing this consent. T4S has given me
sufficient time to review this. I also understand that T4S reserves the right to change its notice and the practices
detailed therin and will provide me with a copy of the revised notice by mail to the address that I have provided.
I understand that I do not have to consent to the use or disclosure of my child’s identifiable health information for
treatment, payment, or health operations, but that if I do not consent, T4S may refuse to provide my child speech
and language services unless applicable state or federal law requires them.
I further understand that I am fully responsible for any and all charges for services rendered.
Parent Signature: _________________________________________________________ Date: ____________
Guardian Signature (if applicable): ___________________________________________ Date: ____________
No alterations, comments, notes, changes, etc are permitted to this agreement without the
express and written consent of the Owner. Any alterations, comments, notes, changes, etc
made to this document will remove any contractual obligation by T4S to seek payment from
Third Parties, provide documentation of service or Evaluations to other Professionals or
Parents.
Table of Contents
New Patient Registration ....................................................................................... 1
Medical History Questionnaire .............................................................................. 3
General Clinic Information ..................................................................................... 7
Clinic Map .............................................................................................................. 8
Financial and Billing Policies................................................................................... 9
Payment Policies .................................................................................................. 11
Consent for Care .................................................................................................. 12
Patient Rights and Responsibilities ...................................................................... 13
Clinic Expectations ............................................................................................... 14
Release of Information ........................................................................................ 15
Release of Medical Records Form ........................................................................ 16
Notice of Privacy Practices ................................................................................... 17
Communication Policies ....................................................................................... 22
Time for Speech Pediatric Speech Therapy, LLC
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New Patient Registration
Patient Name __________________________________ SSN#______________________ Birth Date__________
(last)
(first)
Address______________________________________________________________________________________
(mailing address)
(city)
Home Phone__________________________________
Gender (circle one): M
(state)
(zip)
Cell Phone_________________________________
F
Emergency Contact_____________________________
Phone____________________________________
Mother Name_________________________________
Father Name________________________________
Employer_____________________________________
Employer___________________________________
Birth Date_____________________________________
Birth Date__________________________________
Occupation____________________________________
Occupation_________________________________
Home Phone___________________________________
Home Phone________________________________
Cell Phone_____________________________________
Cell Phone__________________________________
Email _________________________________________
Email ______________________________________
Primary Care Physician_____________________________________________ Phone #___________________
(last)
(first)
Referring Physician________________________________________________ Phone #___________________
(last)
Time for Speech Pediatric Speech Therapy, LLC
(first)
Page 1
PRIMARY INSURANCE INFORMATION:
Insurance Co. Name_____________________________________
Ins. Co. Address____________________________________________________________________________
(mailing address)
(city)
(state)
(zip)
Ins. Co. Phone # _______________________________________
Policy Holder Name___________________________________ Relationship to Patient__________________
Policy Holder SS # ____________________________________ Policy Holder Birth Date _________________
Group # ____________________________________________ Identification # _________________________
SECONDARY INSURANCE INFORMATION
NOT APPLICABLE
Insurance Co. Name ________________________________________________________________________
Ins. Co. Address____________________________________________________________________________
(mailing address)
(city)
(state)
(zip)
Ins. Co. Phone # _______________________________________
Policy Holder Name___________________________________ Relationship to Patient__________________
Policy Holder SS # ____________________________________ Policy Holder Birth Date _________________
Group # ____________________________________________ Identification # _________________________
Time for Speech Pediatric Speech Therapy, LLC
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Medical History Questionnaire
PARENT CONCERN:
Reason for Evaluation:
Previous Diagnosis, if any:
Please circle any areas of development that you may have concerns about:
Attention
Touch
Speech/Language
Eating/Feeding
Nutrition
Temper Tantrums
Hearing
Play
Vision
Behavior
Sleeping
Weight/Growth
Other:
MEDICAL HISTORY
Pregnancy proceeded:
Normally
Please circle any that apply:
Gestational Diabetes
Substance Exposure
Premature Labor
Other:
Motivation
Ability to Calm Self
Movement
Socialization
With Complications: (please list)
Toxemia
Pre-Clampsia
Positive for Strep B
Multiple Births
Positive for Cytomegalovirus
Eclampsia
Length of Pregnancy:
weeks
Prenatal Care was
Received
Not Received
Mother’s age at time of birth:
Length of hospital stay
Delivery was: Vaginal
C-Section
Emergency C-Section
Complications During Delivery: (circle if any)
Premature rupture of membranes
Breech Presentation
Placenta Previa
Abruptio Placenta
Uterine Rupture
Transverse Presentation
Umbilical Cord wrapped around neck Other:
Child’s Birth Weight:
Apgars:
1 minute
lbs.
oz
5 minutes
Birth Length:
10 minutes
Were there significant complications following the birth:
Please list any significant birth complications:
None
Meconium Hypoxia
PDA
Neonatal Hypoxia
ECMO
Positive Dependency
RSV – Respiratory Syncytial Virus
Retinopathy of Prematurity (ROP)
Brochopulmonary Dyspasia (BPD)
Diagnosed/Suspected Syndrome:
YES
None
Use of Forceps
Prolapsed Cord
inches
NO
Respiratory Distress Syndrome
Club Foot
Failure to Thrive
Hyperbilirubinemia
IVH Bleed Oxygen Dependency
Intrauterine Growth Retardation (IUGR)
Respiratory Stridor
VP Shunt
Cytomegalovirus
Anemia of Prematurity
Ventilator Dependency
Other:
Time for Speech Pediatric Speech Therapy, LLC
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CURRENT HEALTH ISSUES/CONCERNS:
Chronic Ear Infection
Anoxic Brain Injury
Asthma/Respiratory
Constipation/Diarrhea
Allergies (please list):
Sleep Problems
Reflux
Colic
Tube Feeding
Traumatic Brain Injury (TBI)
Cerebral Vascular Accident (CVA)
Arteriovenous Malformation (AVM)
Seizure Disorder (Date of last seizure)
Current Medications:
Homeopathy:
Hearing Assessment
Vision Assessment
YES
YES
NO
NO
Date:
Date:
Results:
Results:
Specialists Seen:
Cardiologist
Orthopedic Surgeon
Physician
Rheumatologist
Urologist
Opthamologist
Allergist
ENT
Hand Surgeon
Neurologist
Psychiatrist
Nephrologist
Oncologist
Pediatrician
Podiatrist
Thoracic Surgeon
Audiologist
Geneticist
Endocrinologist
General Surgeon
Internal Medicine
Neuro-Surgeon
Gastroenterologist
Developmental Medicine
Name of specialists currently working with child:
Please indicate any of the following:
Swallow Study (date and place):
BAER (date and place):
MRI/CT Scan/ X-Ray (date and place):
List any previous surgeries: (indicate age at the time of surgery)
Surgery:
Surgery:
DEVELOPMENTAL HISTORY
Motor, Sensory, Play
At what age did your child do the following:
Hold head up alone
Roll over
Sit alone without support
Crawl / Creep alone
Pull self to standing position
Walk unaided
Grab toy
How does your child get around at home?
Does your child fall or lose balance easily?
Time for Speech Pediatric Speech Therapy, LLC
YES
Age:
Age:
NO
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Is your child
RIGHT handed
LEFT handed
No Preference yet
Does your child visually look at people and/or toys?
YES
NO
Does your child show a negative response when touched or when touching objects? YES
Does your child enjoy movement such as swinging or rough housing?
YES
What are your child’s favorite toys and/or play activities?
Does your child play and/or participate in leisure activities daily?
Is your child involved in community programs (school, special rec., scouting etc.)
Feeding, Speech and Language
Does your child have any feeding difficulties? YES
If yes please describe:
When did your child:
Stop using a bottle
Stop using a pacifier
Name familiar objects
Use 2 word combinations
Begin using a cup, sippy cup, straw
Begin eating – Baby Food
List Food Preferences
List Food Dislikes
YES
YES
NO
NO
NO
NO
NO
Finger Food
Table Food
Circle areas of difficulties, if any:
Chewing
Swallowing
Drooling
Tongue Thrust
Sensory
How does your child communicate his/her needs?
Verbalize
Non-verbal Communication
Facial Expressions
Body Language
Pointing/Gesturing
Manual Sign Language
Phrases
Sentences
Augmentative Communication (list)
Do most people understand your child’s speech?
Does your child understand instructions?
YES
YES
Vocalizations
Single Words
Eye Gaze
NO
NO
Please Circle any of the following that may currently describe your child:
Affectionate
Cautious
Shy
Fearless
Distractible
Motivated
Aggressive
Passive
Stubborn
Persistent
Difficult to Comfort
Curious
Active
Fussy
Withdrawn
Playful
Fearful
Demanding
Calm
Insecure
School History
If your child is in school, what grade:
Where:
Does your child have an Individualized Education Plan (IEP)? YES
NO
(please include a copy of most recent IEP)
Has your child had a psychological or neuropsychological evaluation completed?
Time for Speech Pediatric Speech Therapy, LLC
YES
NO
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(please include a copy of the evaluation)
Therapy History
Has your child ever received speech therapy?
Has your child ever received occupational therapy?
Has your child ever received physical therapy?
YES
YES
YES
NO
NO
NO
Physical Therapy:
Location:
Dates of Service:
Therapist/Provider:
Occupational Therapy:
Location:
Dates of Service:
Therapist/Provider:
Speech Language Therapy:
Location:
Dates of Service:
Therapist/Provider:
Social Work:
Location:
Dates of Service:
Therapist/Provider:
Assistive Technology:
Location:
Dates of Service:
Therapist/Provider:
Nutrition:
Location:
Dates of Service:
Therapist/Provider:
Vision Therapy:
Location:
Dates of Service:
Therapist/Provider:
Audiology:
Location:
Dates of Service:
Therapist/Provider:
Behavior Therapy:
Location:
Dates of Service:
Therapist/Provider:
Time for Speech Pediatric Speech Therapy, LLC
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General Clinic Information
Time for Speech Pediatric Speech Therapy, LLC (T4S) specializes in the diagnosis and treatment of
speech and language disorders. T4S was founded in 2009 by a speech language pathologist to
provide children with comprehensive speech and language therapy.
Because we are a fully staffed clinic, T4S is able to provide comprehensive therapy for a wide
spectrum of conditions, including receptive and expressive language delays, articulation disorders,
phonological disorders, apraxia of speech, autism spectrum disorder, aspergers syndrome, aural
rehabilitation for children with hearing loss and cochlear implants, feeding therapy, picture exchange
communication system and voice output device language therapy.
All of our speech–language pathologists pursue on-going training in the newest therapeutic
procedures and techniques. We continually attend training in new diagnostic and therapeutic
procedures, methods and treatments.
Our offices are located at 4050 Lake Otis Parkway Suite 105 (in the Lake Otis Professional and
Medical Center) in Anchorage. Appointments can be made by calling 563-1167.
Patients are encouraged to log on to www.timeforspeechak.com, (Coming soon!) where a variety of
services are available, or e-mail info@timeforspeechak.com.
Contact Information
Phone: (907) 563-1167 and Fax: (907) 563-1169
Call us for:
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New Appointments
Referrals
Cancellations
Directions
Medical Records
Time for Speech Pediatric Speech Therapy, LLC
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Clinic Map
Time for Speech
Pediatric Speech Therapy
4050 Lake Otis Pkwy, Suite 105
907.563.1167
Time for Speech Pediatric Speech Therapy, LLC
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Financial and Billing Policies
T4S strives to provide the finest speech therapy care in Alaska, and to create the best value for our
patients. In order to keep costs as low as possible, we have established the following financial
policies:
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Your portion of payment is due at the time of services (no exceptions).
We accept cash, checks, debit and credit cards.
There will be a $50.00 charge on all NSF checks.
You may pay your bill on line at www.mymedicalbill.net
Regarding Insurance:
We must emphasize that as a medical care provider, our relationship is with you, not your insurance
company. We file your insurance claim as a courtesy, and all charges are ultimately your
responsibility. Not every service is a covered benefit with your plan, and we encourage you to verify
your benefits ahead of time. Some insurance companies arbitrarily select certain services they will
not cover. It is important that you read and understand YOUR health insurance policy and its
requirements for coverage, including preauthorization of services. We currently send claims to
numerous plans and are not responsible for knowing the requirements of your specific plan. We will
not become involved in disputes between you and your insurance company regarding deductibles,
co-payments, covered charges and secondary insurance or “usual and customary” charges. If you
choose to file an appeal to your insurance, it is your responsibility.
As a courtesy to you, we bill your insurance carriers, and will need your help in providing complete
and accurate insurance information. We require this information at least 1 week prior to your initial
visit to verify your insurance benefits to notify you of your deductibles, co-pays, and non-covered
services. Benefits for procedures will also be verified within 48 hours of scheduled services. Your
insurance policy is a contract between you and your insurance company; we are not a party to that
contract. If for any reason your insurance coverage changes, it is your responsibility to inform us in a
timely manner. If you fail to inform us within 30 days of the change, we will not file your insurance.
Please be aware that some, and perhaps all of the services provided may be non-covered services.
Some insurance companies reduce or deny benefits saying they are not considered UCR (usual,
customary or reasonable).
T4S abides by all Federal guidelines regarding insurance billing. As such, we have up to one year to
bill your claim to your insurance carrier. Your health savings account is yours alone to manage.
We are happy to provide statements of remaining balances, but said requests must be made in
writing, via email, fax or postal mail.
We belong to the following insurance networks:
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Medicaid / Denali Kid Care
TriCare
Blue Cross Blue Shield of Alaska
Time for Speech Pediatric Speech Therapy, LLC
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Payment Plans
We are happy to arrange payment plans in advance. Payment plans can be established by contacting
our billing department at least 24 hours prior to your scheduled appointment. These plans require a
signed agreement and a credit card on file.
Refunds
It is our policy to avoid overpayments, but if an overpayment does occur, we will issue a credit to
your account, or issue a monetary refund.
Should you desire a monetary refund, we ask that you make that request in writing. These requests
can take up to 30 days to process. We may not notify you if such a refund is due, and it is your
responsibility to proactively notify us of a monetary refund request. We only issue refunds on net
balances, and only after insurance payments are posted.
Delinquent Accounts
All accounts 90 days past due from Time of Service will be considered delinquents.
Ultimately, your account balance is your responsibility – whether your insurance company pays or
not. All deductibles, co-pays, and non-covered services are due and payable at the time of therapy. It
is your responsibility to ensure that your insurance(s) pay your claim in a timely manner. Delinquent
accounts (90 days) will be charged a 35% administrative fee and will be forwarded to Doctor’s
Collection Services. In the event that your insurance coverage changes to a plan where we are not
participating providers, refer to the above paragraph.
Patient Contact Information
If your address or insurance information changes, please inform us immediately. Failure to do so can
cause delays and keep us from providing the best service possible.
Time for Speech Pediatric Speech Therapy, LLC
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Payment Policies
All payments are due at the time that services are rendered.
Insurance Billing
In an effort to provide the best possible health care and to minimize costs, our staff with verify
health benefits in advance and patients will be responsible for paying the remaining balance when
they visit the T4S office.
T4S will gladly bill insurance carriers, but this service is a courtesy and not a right. Ultimately, the
responsibility for payment rests with the patient.
Coordination of Benefits
Patients are responsible for coordinating their benefits. Any information requested by insurance
carriers is the patient’s responsibility. If benefits are denied for any reason, it is your responsibility to
ensure that payment is made.
Our Fees
Our practice is committed to providing the best treatment for our patients, and we charge what is
representative of the state. You are responsible for payment regardless of any insurance company’s
determination of usual and customary rates.
Payment Plans
T4S offers payment plans to patients. In order to qualify for a payment plan, a valid credit card must
be provided along with a signed payment plan agreement and approval from the Billing Manager.
Payments will be deducted monthly until the balance is paid in full. If you are on a payment plan, it is
your responsibility to notify the Billing Manager of new balances acquired from new dates of service
if you want them added onto the payment plan. Accounts with declined credit cards will be
considered delinquent and will be sent to collections immediately.
Patients with Guardians
If patients have guardians or are accompanied by someone who has Power of Attorney,
documentation of such must be provided prior to the patient’s visit. In these cases the legal guardian
is responsible for payment.
Time for Speech Pediatric Speech Therapy, LLC
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Consent for Care
T4S is committed to providing our clients with the highest standard of therapy. In order to do so, we
need your consent to provide said care. Please fill out the following form, which will allow us to get
involved in your child’s care.
By signing the acknowledgment of receipt on the first page of this packet, I hereby voluntarily
consent to the rendering of such care, including diagnostic evaluations, speech and language
treatment, feeding therapy and aural rehabilitation therapy, as in their professional judgment be
necessary to provide my child with care.
I hereby give permission to T4S in making diagnostic and therapy decisions on my child’s behalf. I
direct that the therapist attempt to inform me beforehand. I authorize the therapist to request,
obtain, review and inspect any and all information bearing upon my child’s health and relevant
information (speech and language evaluations, medical records, IEP’s etc..) with respect to
treatment.
I acknowledge that no guarantees have been made to me or my child as to the effect of such
evaluations or treatment on the condition of my child and that I am responsible for all reasonable
charges in connection with the treatment rendered to my child during this period.
I consent to have information related to my child’s health/speech and language released to the
following individuals or organizations:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
By signing the acknowledgment of receipt on the first page of this packet, I consent for my child to
receive treatment and have information about my child’s treatment released to those individuals
named above.
There is a Release of Information following this page, please complete this form if you would like us
to receive information regarding previous speech and language services, school district information,
audiology information and/or general information from other professionals.
Time for Speech Pediatric Speech Therapy, LLC
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Patient Rights and Responsibilities
At Time for Speech, the patient has the right to:
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Considerate and respectful care
Knowledge of the name of the speech language pathologist who has primary responsibility
for coordinating the care and the names and professional relationships of other speech
language pathologists and student clinicians who will see the child.
Receive as much information about any proposed treatment or procedures as the child may
need in order to give informed consent or to refuse this course of treatment. This
information shall include a description of the goals and objectives related to the treatment
plan, evaluation results, therapeutic techniques and alternate forms of techniques and to
know the name of the person who will carry out speech and language therapy.
Participate actively in any decisions regarding therapy.
Full consideration of privacy concerning the therapeutic program. Case discussions,
consultation, evaluation and treatment are confidential and should be conducted discreetly.
The patient has the right to be advised as to the reason for the presence of any individual.
Confidential treatment of all communications and records pertaining to his/her therapy.
Reasonable continuity of treatment and to know in advance the time and location of
appointments as well as the identity of therapists providing therapy.
Have all patient’s rights apply to the person who may have legal responsibility to make
decisions regarding therapeutic care on behalf of the patient.
Have complaints forwarded to Administrative personnel for appropriate response.
Know that all the T4S personnel will observe these patient’s rights.
Parent/ Patient Responsibilities
The therapy a patient receives depends partially on the patient and/or parent. Therefore, in addition
to their rights, a parent/child has certain responsibilities as well.
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The parent/patient has the responsibility to provide accurate and complete information
concerning his/her present concerns, past medical/speech and language history, and other
matters relating to his/her concerns.
The parent/patient is responsible for making it known whether he/she clearly comprehends
the course of his/her (child’s) therapy treatment and what is expected of him/her.
The parent/patient is responsible for following the treatment plan established by his/her
speech language pathologist, including the instructions of other speech therapists as they
carry out the prescribed treatment plan.
The parent/patient is responsible for keeping appointments and for notifying the office or
speech language pathologist when he/she is unable to.
The parent/patient is responsible for his/her actions should he/she refuse treatment or not
follow suggestions.
The parent/patient is responsible the financial obligations of his/her care.
The parent/patient is responsible for being considerate of the rights of other patients and
office personnel.
Time for Speech Pediatric Speech Therapy, LLC
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Clinic Expectations
Commitment Guidelines
We at T4S are committed to your child’s care and your appointment time is reserved exclusively for
you. We understand that with life’s uncertainties you may need to cancel your child’s appointment.
If so, please give our staff a (if possible) minimum of 24 hours notice.
Our speech therapists dedicate 45 minutes of patient care for you/your child, our new patient. Our
therapists take your child’s speech and language needs very seriously. We also reserve the right to
request payment up front. We would prefer not to enforce this right, but will if it becomes
necessary. Repeated missed or cancelled appointments may be the basis for termination of service.
Please be advised that the staff of Time for Speech reserves the right to reschedule patients who
arrive more than 15 minutes late for their scheduled appointment time.
No Show Policy
At T4S we do enforce a No Show Policy as follows:
First NO SHOW – this means you miss your appointment without calling to cancel – you will
be charged $50.00 NOT your insurance company.
Second NO SHOW – this means you miss your appointment without calling to cancel – you
will be charged $100.00 NOT your insurance company.
Third NO SHOW – this means you miss your appointment without calling to cancel – you will
be charged $100.00 and your child will be removed from the schedule.
Respect for Others
We also ask that people keep in mind that T4S is a therapy clinic, and as such, there are often young
children present. We expect everyone to treat each other with courtesy and respect, including our
speech therapists, our staff and other patients. Abusive and unacceptable behavior will not be
tolerated, and if we deem a patient’s behavior as unacceptable, we will refer them to another
provider.
Please remember that our clinic is located in a professional and medical center and that everyone
should treat the other businesses located within the building with courtesy and respect by not
allowing children to run through the hallways or up and down the stairs during regular business
hours.
Phone Calls
T4S has voicemail 24 hours a day, 7 days a week. If you need to reach your therapist, please feel free
to leave a message and we will return your call as soon as possible.
Payment for Services
Your portion of payment is due at the time of service.
Time for Speech Pediatric Speech Therapy, LLC
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Release of Information
At T4S, medical/therapy records are maintained in electronic and paper format, in compliance with
HIPAA and our in-house privacy policies.
For a copy of your medical record, please fill out the form on the following page.
Third Party Requests
Third parties, such as attorneys, school district employees, or the State of Alaska may request a copy
of your child’s medical/therapy records as well, provided the release on the following page.
Requests for Other Therapy Clinics
Requests from other therapy clinics are free of charge
In order to make a medical/therapy records request, patients much first fill out the Release of
Medical Records form, located on the next page.
Please allow five days for processing.
Time for Speech Pediatric Speech Therapy, LLC
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Authorization to Release Medical/Clinical Records Form
Name:______________________ Phone:______________
Date of Birth:____/____/______
S.S #________________
____ I hereby authorize TIME FOR SPEECH PEDIATRIC SPEECH THERAPY to Obtain Information from:
Person/Agency:____________________________________________________________________
Address:__________________________________________________________________________
City, State, Zip: ____________________________________________________________________
Phone #: _________________________________________________________________________
____ I hereby authorize TIME FOR SPEECH PEDIATRIC SPEECH THERAPY to Release Information to:
Person/Agency:____________________________________________________________________
Address:__________________________________________________________________________
City, State, Zip: ____________________________________________________________________
Phone #: _________________________________________________________________________
REQUESTED INFORMATION TO BE RELEASED
o EVALUATION REPORT
o PROGRESS NOTES
o PLAN OF CARE
o HEALTH/MEDICAL HISTORY
o OTHER AS SPECIFIED BELOW:
o
o
o
o
o
PURPOSE OF RELEASE
EDUCATIONAL USE
COORDINATION OF CARE
CONTINUED TREATMENT
LITIGATION
OTHER AS SPECIFIED BELOW :
________ I have been provided a copy of TIME FOR SPEECH PEDIATRIC SPEECH THERAPY’s Notice of Privacy Practices and any changes
that may be associated with this authorization. I have discussed any concerns I may have about the use, release and disclosure of my
health information disclosed under this authorization. I release TIME FOR SPEECH PEDIATRIC SPEECH THERAPY from any legal liability
that may arise from this authorization.
________ The parent/patient may revoke this authorization by notifying in writing TIME FOR SPEECH PEDIATRIC SPEECH THERAPY’s
designated Privacy Officer. Federal Law states that treatment, payment, enrollment, or eligibility for benefits may not be conditioned
on obtaining this authorization if such conditioning is prohibited by the Privacy Rule. Federal Law also requires a statement that there is
the potential for the protected health information released under this authorization may be subject to re-disclosure by the recipient.
Signature of Parent or Patient __________________________________ Date _____/______/______
Relationship to Patient ______________________________ Witness __________________________
This authorization shall be in effect for 90 days following the date of signature.
Time for Speech Pediatric Speech Therapy, LLC
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Notice of Privacy Practices
T4S is committed to upholding patient privacy standards in accordance with the Health Insurance
Portability and Accountability Act (HIPAA) of 1996. Our staff is accountable for preserving the privacy
and confidentiality of your child’s health information which is created and/or maintained at our clinic.
State and federal laws and regulations require use to implement policies and procedures to
safeguard the privacy of your child’s health information. This notice will provide you with information
regarding our privacy practices and how it applies to all of your child’s health information created
and/or maintained at our clinic, including any information that we receive from other health care
providers or facilities. The Notice describes your rights and our obligations concerning such uses or
disclosures.
We will abide by the terms of this Notice, including any future revisions that we may make to the
Notice as required or authorized by law. We reserve the right to change this Notice and to make the
revised or changed Notice effective for health information we already have about your child, as well
as any information we receive in the future. We will post a copy of the current Notice which will
identify its effective date in our clinic.
The privacy practices described in this Notice will be followed by:
Any health care professional authorized to enter information into your medical record created and/or
maintained at our clinic.
All employees, students, contractors, and other service providers who have access to your child’s
health information at our clinic; and
Any member of a volunteer group that is allowed to help your child while receiving services at our
clinic.
The individuals identified above will share your health information with each other for purposes or
treatment, payment and health care operations, as further described in the Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION FOR TREATMENT, PAYMENT AND
HEALTH CARE OPERATIONS
1.
Treatment, Payment and Health Care Operations. The following section describes different
ways that we may use and disclose your health information for purposes of treatment,
payment and health care operations. We explain each of these purposes below and include
examples of the types of uses or disclosures that may be made for each purpose. We have
not listed every type of use or disclosure, but the ways in which we use or disclose your
child’s information will fall under one of these purposes
a. Treatment. We may use your health information to provide your child with speech
and language treatment and services. We may disclose your health information to
doctors, nurses, nursing assistants, school district employees, student clinicians,
rehabilitation therapy specialists, or other personnel who are involved in your child’s
health care.
For example, we may refer your child to a physical or occupational therapist to
improve sensory awareness/motor control. We will need to talk with the physical or
occupational therapist so that we can coordinate services or discuss therapy
techniques that best suit your child’s needs. We may also need to refer you to
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another therapist / therapy discipline to receive such services. We will share
information with that health care provider in order to coordinate your child’s care
and services.
b. Payment.
We may use or disclose your child’s health information so that we may
bill and receive payment from you, an insurance company, or another third party for
the health care services you receive from us. We also may disclose health information
about you to your health plan in order to obtain prior approval for the services we
provide to your child, or to determine that your health plan will pay for the
treatment.
For example, we may need to give health information to your health plan in order to
obtain prior approval to provide speech and language services, feeding therapy or
therapeutic services for non-speech generating devices.
c. Health Care Operations, We may use or disclose your child’s health information in
order to perform the necessary administrative, educational, quality assurance and
business functions at our clinic.
For example, we may use your child’s health information to evaluate the
performance of our staff in caring for your child. We also may use your child’s health
information to evaluate whether certain treatment or services offered by our clinic
are effective. We also may disclose your child’s health information to other
physicians, therapists, disciplines, and/or educational staff for teaching and learning
purposes.
USES AND DISCLOSURES OF HEALTH INFORMATION IN SPECIAL SITUATIONS
We may use or disclose your child’s health information in certain special situations as described
below. For these situations, you have the right to limit these uses and disclosures as provided for in
this Notice.
1.
Appointment Reminders We may use or disclose your child’s health information for
purposes of contacting you to remind you of an appointment.
2. Treatment Alternatives & Health-Related Products and Services We may use or disclose
your child’s health information for purposes of contacting you to inform you of
treatment alternatives or health-related products or services that may be of interest to
you or your child. For example, if your child is diagnosed with a specific condition, we
may contact you to inform you of an instruction class that is offered for your child’s
condition.
3. Family Members and Friends
We may disclose your child’s health information to
individuals, such as family members and friends, who are involved in your child’s care or
who help pay for your child’s care. We may make such disclosures when: (a) we have
your verbal agreement to do so; (b) we make such disclosures and your do not object; (c)
we can infer from the circumstances that you would not object to such disclosures. For
example, if your spouse comes into the therapy room with your child, we will assume
that you agree to our disclosure of your child’s information while your spouse is present
in the room.
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We may also disclose your child’s health information to family members or friends in
instances when you are unable to agree or object to such disclosures, provided that we
feel it is in your child’s best interest to make such disclosures and the disclosures relate to
that family member or friend’s involvement in your child’s case. For example, if you
present our clinic with an emergency medical condition, we may share information with
the family member or friend that comes with you and your child to our clinic.
4. Billing and Financial
We may disclose your child’s health information to third pary
collection agencies if we deem it necessary.
OTHER PERMITTED OR REQUIRED USES AND DISCLOSURES OF HEALTH INFORMATION
There are certain instances in which we may be required or permitted by law to use or disclose your
child’s health information without your permission. These instances are as follows:
1.
2.
3.
4.
5.
6.
7.
8.
As required by law
We may disclose your child’s health information when
required by federal, state or local law to do so. For example, we are required by the
Department of Health and Human Services (HHS) to disclose your child’s health
information in order to allow HHS to evaluate whether we are in compliance with the
federal privacy regulations.
Public Health Activities We may disclose your child’s health information to public
health authorities that are authorized by law to receive and collect health information for
the purpose of preventing or controlling disease, injury, or disability; to report births,
deaths, suspected abuse or neglect, reactions to medications.
Health Oversight Activities
We may disclose your child’s health information to a
health oversight agency that is authorized by law to conduct health oversight
information to health oversight investigations, inspections, or licensure and certification
surveys. These activities are necessary for the government to monitor the persons or
organizations that provide health care to individuals and to ensure compliance with
applicable state and federal laws and regulations.
Judicial or administrative Proceedings We may disclose your child’s health information
to courts or administrative agencies charged with the authority to hear and resolve
lawsuits or disputes. We may disclose your child’s health information pursuant to a court
order, a subpoena, a discovery request, or other lawful process issued by a judge or other
person involved in the sipute, but only if efforts have been made to (i) notify you of the
request for disclosure or (ii) obtain an order protecting your child’s health information.
Worker’s Compensation We may need to disclose your child’s health information to
worker’s compensation programs when your health condition arises out of work-related
illness or injury.
Law Enforcement Officials We may disclose your child’s health information to a request
received from a law enforcement official to report criminal activity or to respond to a
subpoena, court order, warrant, summons, or similar process.
Coroners, Medical Examiners, or Funeral Director We may disclose your child’s health
information to a coroner or medical examiner for the purpose of identifying a deceased
individual or to determine the cause of death. We also may disclose your child’s health
information to a funeral director for the purpose of carrying out his/her necessary
activities.
Organ Procurement Organizations or Tissue Banks If your child is an organ donor, we
may disclose your child’s health information to organizations that handle organ
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9.
10.
11.
12.
procurement, transplantation, or tissue banking for the purpose of facilitating organ or
tissue donation or transplantation.
Research We may use or disclose your child’s health information for research purposes
under certain limited circumstances. Because all research projects are subject to a special
approval process, we will not use or disclose your child’s health information for research
purposes until the particular research project for which your child’s health information
may be used or disclosed has been approved through this special approval process.
However, we may use or disclose your child’s health information to individuals preparing
to conduct the research project in order to assist them in identifying patients with
specific speech and language disorders who may qualify to participate in the research
project. Any use or disclosure of our health information which is done for the purpose of
identifying qualified participants will be conducted onsite at our facility. In most
instances, we will ask for your specific permission to use or disclose your child’s health
information if the researcher will have access to your child’s name, address, or other
identifying information.
To Avert a Serious Threat to Health or Safety
We may use or disclose your child’s
health information when necessary to prevent a serious threat to the health or safety of
you or other individuals.
Military and Veterans If you are a member of the armed forces, we may use or disclose
your child’s health information as required by military command authorities.
National Security and Intelligence Activities We may use or disclose your child’s health
information to authorized federal officials for purposes of intelligence,
counterintelligence, and other national security activities, as authorized by law.
USES AND DISCLOSURES PURSUANT TO YOUR WRITTEN AUTHORIZATION
Except for the purposes identified above, we will not use or disclose your child’s health information
for any other purposes unless we have your specific written authorization. You have the right to
revoke a written authorization at any time as long as you do so in writing. If you revoke your
authorization, we will no longer use or disclose your health information for the purposes identified in
the authorization, except to the extent that we have already taken some action in reliance upon your
authorization.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
You have the following rights regarding your child’s health information. You may exercise each of
these rights, IN WRITING, by providing us with a completed form that you can obtain from the
business office. In some instances, we may charge you for the cost(s) associated with providing you
with the requested information. Additional information regarding how to exercise your rights, and
the associated costs, can be obtained from our business office.
1.
Right to Inspect and Copy
You have the right to inspect and receive copies of health
information that may be used to make decisions about your child’s care. We may deny your
request in inspect and copy your child’s health information in certain limited circumstances. If
you are denied access to your child’s health information, you may request that the denial be
reviewed.
2. Right to Amend
You have the right to request an amendment of your child’s health
information that is maintained by or for our clinic and is used to make health care decisions
about your child. We may deny your request if it is not submitted in writing or does not
include a reason to support your request. We may also deny your request if the information
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3.
4.
5.
6.
sought to be amended: (a) was not created by us, unless the person or entity that created
the information is no longer available to make the amendment; (b) is not part of the
information that is kept by or for our clinic; (c) is not part of the information which you are
permitted to inspect and copy; (d) is accurate and complete.
Right to an Accounting of Disclosures You have the right to request an accounting of the
disclosures of your child’s health information made by us. This accounting will not include
disclosures of health information that we made for purposes of treatment, payments, or
health care operations or pursuant to a written authorization that you have signed.
Right to Request Restrictions You have the right to request a restriction or limitation on
the health information we use or disclose about your child for treatment, payment or health
care operations. You also have the right to request a limit on the health information we
disclose about your child to someone, such as family member or friend, who is involved in
your child’s care or in the payment of your child’s care. For example, you could ask that we
not use or disclose information regarding a particular treatment that your child received. We
are not required to agree to your request. If we do agree, that agreement must be in writing
and signed by you and us.
Right to Request Confidential Communications
You have the right to request that we
communicate with you about your child’s therapy in a certain way or at a certain location. For
example, you can ask that we only contact you at work or by mail.
Right to a Paper Copy of this Notice
You have the right to receive a paper copy of this
Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed
to receive this Notice electronically, you are still entitled to a paper copy of this Notice.
QUESTIONS OR COMPLAINTS
If you have any questions regarding this Notice or wish to receive additional information about our
privacy practices, please contact our Privacy Officer at 563-1167. If you believe your privacy rights
have been violated, you may file a complaint with our clinic or with the Secretary of the Department
of Health and Human Services (HHS). To file a complaint with Time for Speech Pediatric Speech
Therapy, LLC, contact our Privacy Officer at 4050 Lake Otis Parkway Suite 105, Anchorage, Alaska
99508.
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Communication Policies
Telephone / Messages
T4S has voicemail 24 hours a day, 7 days a week. Please call with any questions, concerns, and/or
cancellations. If you would like us to call you, please leave ONE voicemail message. If we receive the
message before 4 p.m., it will be returned in the same business day. Please be aware that not all
therapists work each day, if you leave a message for a specific speech pathologist, your phone call
will be returned as soon as he/she returns to the office.
Appointments
Appointments can most efficiently be made via telephone or our website at
www.timeforspeechak.com (Coming Soon!). If you would prefer to make an appointment over the
telephone, please call 563-1167.
Referrals
Referrals from physicians and/or therapists can take up to five business days to process. The referral
process includes gathering all required information including concerns, insurance information, and
availability for appointment times. Our staff will promptly contact you as soon as the referral is
processed. After 48 hours, please feel free to follow up with us.
Communication with our Staff
We expect all of our staff to be treated with courtesy and respect. Any patient who fails to do so will
be referred to another provider.
E-mails
At T4S, we strongly encourage the use of e-mail. The use of electronic mail establishes accurate
records and helps us to provide highly personalized care. All inquires may be sent to
info@timeforspeechak.com, where they will be promptly routed to the appropriate staff member
and returned by the next business day.
Website
Our website, www.timeforspeechak.com (Coming Soon!), is a comprehensive resource for patients.
It provides information on our clinic, providers and services. It also allows patients to pay bills online
and effectively communicate with staff.
Faxes
Faxes may be sent to 563-1169. Please allow 24 hours for processing.
Contacting Providers
Our providers are tasked with providing direct therapy services and rely on support staff for all nontherapy related issues. Therefore, we ask that you communicate with our practice via the means
outlined above.
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