Teletherapy Consent
Informed Consent to Participate in Telepractice/Telehealth/Telemedicine for Speech, Language, Fluency, Feeding and other related therapies with SAGE Speech & Learning Associates, LLC
What is Telepractice?
According to the American Speech-Language Hearing Association (ASHA), Telepractice is the application of telecommunications technology to the delivery of speech language pathology and audiology professional services at a distance by linking clinician to client or clinician to clinician for assessment, intervention, and/or consultation.
Who Provides Telepractice Services?
A licensed speech-language pathologist working behalf of SAGE Speech & Learning Associates will provide telepractice services.
What information may be shared over telepractice?
All information that would usually be shared in an assessment, treatment or consultation session may be shared during telepractice sessions.
What technology platform will be used for telepractice?
SAGE Speech & Learning Associates uses the Theranest TokBox platform, a HIPAA compliant telehealth tool.
Child's Name
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Child's DOB
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Person Completing This Form
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Relationship to the Child
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By signing this form, I am consenting that my child, named above, may participate in remote treatment (telepractice/telehealth, telemedicine) with providers at SAGE Speech & Learning Associates. Remote treatment is voluntary. All tele practice services will be delivered in compliance with state and federal laws, as well as HIPAA laws.
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Yes
I understand that all scheduling, billing, cancellation and confidentiality policies that were signed upon starting treatment with SAGE Speech & Learning Associates will remain in effect for tele practice services.
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Yes
I understand that Medicaid and other commercial Insurance Companies that SAGE Speech & Learning Associates is in network with may not cover telepractice. The State of Georgia does have a parity law for coverage of telemedicine/telehealth/telepractice services, which can be found here: https://evisit.com/state-telemedicine-policy/georgia/
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Yes
I understand that if I already have up to date insurance information for either Medicaid or Blue Cross Blue Shield/Anthem on file with SAGE Speech & Learning, that SAGE Speech & Learning will submit claims to those payor's on my behalf for teletherapy services.
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Yes
I understand the in the event that Medicaid and other commercial insurance companies that SAGE Speech & Learning Associates is in network with do not cover telepractice/teletherapy services, it is patient responsibility to provide full payment by the payment due date outlined in the SAGE Speech & Learning policy forms that I signed upon beginning treatment.
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Yes
Please address any questions regarding teletherapy/telepractice/telemedicine/telehealth to SAGE Speech & Learning Associates, 404-245-7981, Saren@sagespeech.com
Parent/Guardian Name
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Date
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Signature of Parent/Guardian
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Submit
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