Patient Intake Form

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 pictures and/or video or voice record children while working with them. With video/voice recording, we are able to review performance and critique therapy practices to make them more effective for each client. We can also use video/voice recording to compare performance at different times during therapy to show growth. Photos are important as data collection and to be able to send home quick images of your child completing therapy tasks or communicating something new.

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, C DSA, 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.

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