Consent for Existing Patients

USES AND DISCLOSURES OF HEALTH INFORMATION Cheshire Center uses your personal health information primarily for evaluation and treatment; obtaining payment for treatment; conducting internal administrative activities and evaluating the quality of care that we provide. For example, Cheshire Center may use your personal health information to contact you via phone, email or text message to provide appointment reminders or information about treatment. We may share your health information for continuing, planning and coordinating treatment with appropriately related facilities or professionals involved with your care. Cheshire Center may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law. Cheshire Center's policy is to obtain your written authorization before disclosing your personal health information. Cheshire Center may change its policy at any time. When changes are made, a new Notice of Information Practices will be posted in the waiting room and patient exam areas and will be provided to you on your next visit. You may also request an updated copy of our Notice of Information Practices at any time. If you are concerned that Cheshire Center may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact our practice. You may also send a written complaint to the US Department of Health and Human Services.

PATIENT'S INDIVIDUAL RIGHTS You have the right to review or obtain a copy of your personal health information, request corrections to any inaccurate or incomplete information, and request a list of instances where your information has been disclosed for purposes other than treatment, payment, or administrative needs. Our practice maintains HIPAA compliance for all records and documentation we generate and store. Please note that if you choose to record your child’s session (audio or video), that recording will not be maintained or protected by our practice and may not be HIPAA-compliant. By choosing to record, you accept responsibility for safeguarding the recording and for any disclosures of information it may contain. You may also request, in writing, that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. Cheshire Center will consider all such requests on a case by case basis, but the practice is not legally required to accept them.

CONSENT FOR CARE: I grant permission to the professional staff or their designees at Cheshire Speech & Voice Center, Inc. to render treatment or diagnostic procedures as deemed necessary during my care. I am aware that the practices of speech - language pathology and audiology are not exact sciences and acknowledge that no guarantees have been made regarding the result of treatments or evaluations.

VIRTUAL THERAPY INFORMED CONSENT: I understand that I (legal guardian of patient) may engage in virtual therapy (teletherapy) with my Cheshire Center provider. I understand that virtual therapy services are not the same as in person therapy sessions and that to achieve the best results, I should be in a quiet place with limited interruptions when I am engaged in each session. I understand the potential risks to this technology include interruptions, unauthorized access and technical difficulties. I understand that online therapy presents unique risks to my confidentiality including variables on my end such as others in the vicinity overhearing the session or captured internet transmissions. I understand my provider will inform me and obtain my consent if another person is present during the session and I agree to inform my provider if there is another person present during the session. I understand that I cannot record virtual sessions. I understand that I may work with my provider and withdraw my consent for virtual services at any time and that my provider may terminate virtual therapy if they deem it inappropriate for me to continue under this service delivery model. I understand that Cheshire Center will make every effort to confirm that my commercial or private insurance will cover virtual therapy and that I am financially responsible. (Excludes Medicaid and NC Healthchoice)

CONSENT FOR SERVICES PROVIDED BY SLP-ASSISTANT: Cheshire employs NCBOE registered Speech Language Pathology Assistants under the direction of Certified Speech Language Pathologists in accordance with strict NCBOE licensing requirements and scope of practice guidelines. Speech therapy services at Cheshire may be delivered by both SLP-Assistants and SLPs.

AUTHORIZATION TO PHOTO, VIDEO, VOICE RECORD: As part of the assessment and therapy process, it is often helpful to take photographs, video recordings, or voice recordings of children while working with them. These recordings allow us to review performance, critique therapy practices to improve effectiveness, and compare progress over time. Photos are also useful for data collection and for sharing quick images of your child demonstrating new skills. Please note that video recordings may occasionally be taken on non-HIPAA compliant devices for therapeutic purposes. Parents/guardians have the right to decline or withdraw permission for photography, video, or voice recording at any time by submitting a written request.

AUTHORIZATION FOR USE OR RELEASE / DISCLOSE OF INFORMATION: I authorize Cheshire Speech & Voice Center, Inc. to release clinical information and billing information including, but not limited to, information about my diagnosis, care and treatment for the following reasons.

FINANCIAL COVERAGE: To any third party or its agents requesting clinical and other information for the purpose of determining eligibility for insurance or other public benefits; processing insurance claims; or assessing quality, cost and appropriateness of care.

USE OR DISCLOSURE FOR CONTINUED CARE: To the referring party or to any physician, therapist, extended care facility, hospital, home health care agency, LEA / school, day care, CDSA, child service coordinator, early interventionist or other such institution needing such information for continued care.

AUTHORIZATION TO REQUEST INFORMATION: I authorize Cheshire Speech & Voice Center, Inc. to request any information needed for continued care from any physician, therapist, extended care facility, hospital, home health care agency, LEA / school, day care, CDSA, child service coordinator, early interventionist or other such institution.

AUTHORIZATION FOR RELEASE OF CURRENT CLINICAL INFORMATION: I authorize Cheshire Speech & Voice Center, Inc.to release clinical information contained in evaluations completed by a g encies other than Cheshire Speech & Voice Center, Inc. to any third party or its agents requesting clinical and other information for the purpose of determining eligibility for insurance or other public benefits; processing insurance claims; or assessing quality, cost, and appropriateness of care.

AUTHORIZATION FOR PAYMENT OF MEDICAL BENEFITS: I authorize billing of insurer by Cheshire Speech and Voice Center and payment of medical benefits to Cheshire Speech & Voice Center, Inc. for services rendered.

WAIVER, RELEASE, INDEMNIFICATION AND COVENANT NOT TO SUE: In consideration of Minor’s participation in Cheshire Center programs I, in my legal capacity as parent / guardian of Minor agree on behalf of myself and Minor that The Cheshire Speech and Voice Center it’s officers, directors, agents, employees, insurers, and representatives (“Releasees”) will not be liable for any personal injury, property damage, disability, death, sickness, or disease incurred by Minor, however occurring, including but not limited to the negligence of releases. I understand that Minor and I will be solely responsible for any loss, damage including personal injury, disability, or sickness sustained from participation in our services.

COPARENTING POLICY: Cheshire Speech & Voice Center, Inc. recognizes that many of the families we serve are navigating coparenting dynamics. In order to provide a supportive and respectful environment for all families, we have established the following policies. Your signature on this document indicates you understand and agree to the following: -Equal Parental Rights: Both parents have equal rights to attend treatment sessions and access patient records. If there are any special circumstances that affect this arrangement (such as a custody agreement), please provide a copy of the custody order and/or parenting agreement as soon as possible. Please allow up to one week for us to process any necessary changes based on this documentation. We cannot exclude one parent from the treatment process based solely on the preference of the other. -Communication Expectations: It is the responsibility of the parents to communicate with each other regarding therapy schedules, progress, and cost. -Scope of Practice: Our clinicians are specialists in speech-language therapy. Assessing the nature of a parent-child relationship or making custody-related recommendations is outside of our professional scope. We will only testify or provide documentation related to the child's therapy progress and treatment. - Legal Involvement Fees: - Expert Testimony: $150.00 per hour (includes travel and wait times) plus $0.70 per mile from our office to the courthouse. A subpoena is required, and your attorney must provide questions at least 24 hours in advance for adequate preparation. - Notarized Documentation: $100.00 (subpoena required). Non-notarized daily notes, progress reports, and evaluations are available at no cost. We do not provide letters of recommendation or support for custody arrangements. - Handling of Coparenting Issues: All matters related to coparenting conflict will be addressed by the Clinical Director, Laura Michael. This ensures your child’s therapist and our administrative team can remain focused on delivering high-quality care.

I HAVE READ AND UNDERSTAND THIS INFORMATION.I HAVE RECEIVED A COPY.I AM EITHER THE PATIENT OR I AM AUTHORIZED TO ACT ON BEHALF OF THE PATIENT TO SIGN THIS FORM.

I have read and fully understand Cheshire Center's Notice of Information Practices. I understand that Cheshire Center may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time. I also understand that Cheshire Center will consider requests for restriction on a case by case basis, but does not have to agree to requests for restrictions. I hereby consent to the use and disclosure of my personal health information for purposes as noted in Cheshire Center's Notice of Information practices.

I HAVE READ AND UNDERSTAND THIS INFORMATION. I HAVE RECEIVED A COPY. I AM EITHER THE PATIENT OR I AM AUTHORIZED TO ACT ON BEHALF OF THE PATIENT TO SIGN THIS FORM.

Thank you for choosing Cheshire Center! We are committed to your entire experience being successful. We will need complete and accurate payment and insurance information. If you have commercial insurance or are private pay, you will need to speak to our billing specialist in order to have a general understanding of your financial responsibility prior to seeing one of our therapists.

Your account balance is due weekly. We require a form of payment being placed on file prior to services being provided. Payment will be automatically deducted the week after services are provided. Acceptable payment options include Visa, Mastercard, FSA, and Care Credit. Unpaid balances are subject to collections through an outside agency.

Make up visit policy: Plans of care are written based on medical necessity. Should services be missed, make up services will be provided.

Medicaid or NC Healthchoice patients: We do not require a form of payment on file. You are financially responsible for services rendered and a form of payment will be required to continue services should you lose your coverage.

Sometimes your insurance may change during the course of treatment services. You are required to notify us immediately and provide updated information. Our billing specialist may be reached at 336-375-2240.

I have read and understand the payment contract and agree to abide by this policy.