Consent Forms

I authorize The Learning Sphere (TLS) to render appropriate evaluations, therapy services, and consultations to myself/ child in accordance with state and federal laws. I understand that care will be provided by a qualified, licensed, and trained health professional. I recognize, agree and understand that I have the right to refuse treatment or terminate services at any time by TLS in writing. In addition, TLS may terminate services by notifying me. My signature on this consent form verifies that I agree to the terms and conditions .

 This authorization for release of information covers the period of healthcare from:

1. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation or other purposes as I may direct.

2. This authorization shall be in force and effect until one year from the date of my signature, at which time this authorization expires.

3. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

4. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

5. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

I,(parent/guardian), acknowledge and agree to have myself/ my child receive services from The Learning Sphere and/or any employee, independent contractor employed by The Learning Sphere. By signing  below, I acknowledge the following risks and agreements as they relate to The Learning Sphere (TLS) it s, employees, volunteers, students, interns, agents, contractors, lessors, sublessors, and affiliates:

I am fully authorized to make decisions for myself/ the child listed above as a fully responsible parent or guardian.

I acknowledge that there is some inherent risks associated with the use of therapy equipment and services. I acknowledge that TLS will only supervise my child when he/she is receiving services from TLS.

Patient Financial Responsibility

Not an In-network Provider: The Learning Sphere accepts credit card payments (including HSA payments). We are out-of-network with insurance providers. However, The Learning Sphere will provide documents that can be used by a family to request coverage by an insurer. Families are responsible for submiting claims documents to their insurer. The Learning Sphere will not submit any claims to any insurance provider. 

Credit Card on File: To facilitate a seamless and efficient payment process, we  require all parents/guardians to provide a credit card to be kept on file. This card will be securely stored, and charges will only be processed for completed sessions. 

Automatic Payment Terms: We will charge your card for uncharged, completed therapy session/s after your child's session/s or at the end of each week. We will inform you if your credit card will be processed for No Show or Late Cancellation Fees: https://www.thelearningsphere.com/cancellation-refund-policy.html 

My signature on this form, as a parent or guardian of a child receiving services at The Learning Sphere (TLS), indicates that I have read, understand, and agree to the TLS automatic payment terms indicated above.

I am aware of the cost of therapy sessions, no show fees, and late cancellation fees, which can be found at these links:

-Speech therapy Costs: https://www.thelearningsphere.com/purchase-speech-therapy.html

-Feeding Therapy Costs https://www.thelearningsphere.com/purchase-feeding-therapy.html

-No Show or Late Cancellation Fees: https://www.thelearningsphere.com/cancellation-refund-policy.html 

I understand that my information will be securely saved on-file for to pay for recurring speech or feeding therapy sessions. I agree that my signature on this Agreement shall be deemed as my signature on recurring service charges. 

 
By signing this Agreement, I (parent/guardian) authorize The Learning Sphere to charge the credit/debit card that I have provided for all amounts owed for my child’s session/s. 

 

A consistent schedule is pertinent to your/your child’s progress in speech-language therapy. We require that you notify us 24 hours prior to your appointment if you need to cancel or reschedule an appointment.

CANCELLATIONS: Except for emergency situations, all appointments must be cancelled at least 24 hours in advance by calling or emailing. We consider the following to be examples of NON EMERGENCY reasons to cancel an appointment: vacations, prescheduled doctor appointments, family events, parties, recreational events, after school activities, lack of baby sitter, car trouble, traffic, holiday weekend, school holiday, day before or after a holiday, schedule conflict, and sibling illness.

CANCELLATION FEE: Appointments that are not cancelled at least 24 hours in advance of the scheduled appointment will be charged a late cancellation fee of $50. 

No Show without Notification: All appointments that are missed without notification will be charged either $50 or 50% of the rate of the missed appointment. This fee is not covered by insurance or other third party payer and must be paid in full no later than your next appointment.

Patient will not be seen if late cancellation fee has not been paid. Missed visits in a group therapy session will be charged the rate for that session. This fee is not covered by insurance or other third party payer and must be paid in full no later than your next appointment. Patient will not be seen if late cancellation fee has not been paid.

If you/your child misses 3 or more scheduled sessions within a 3-month period, The Learning Sphere reserves the right to cancel all future appointments.

EMERGENCY CANCELLATIONS: In case of emergency (sudden illness, death in family, hospitalization, emergency doctor visit), appointment must be cancelled as early as possible prior to appointment time. There is no charge for an emergency related cancelled appointment. 

Please keep your child at home for 24 hours after the last occurence of fever, vomiting, or diarrhea. Use your best judgement if your child is sneezing, coughing, or has a runny nose and is not able to cover a cough or use a Kleenax by him/herself.  You will not be charged a cancellation fee if you have an 85% attendance rate or a doctor’s note.We appreciate your understanding and will be happy to reschedule your appointment. We have a 24-hour answering service/email, please contact us at any hour and leave a message.

Inclement Weather: The Learning Sphere reserves the right to cancel or reschedule appointments in the event of inclement weather. We follow the same inclement weather policy as Spring Branch ISD. If Spring Branch ISD closes for the day, we will cancel all appointments for that day. Please contact us to reschedule in the event of a weather related cancellation.

REFUND POLICY:

A 3% fee will be deducted from any requested credit card refunds ( in order to cover the cost of our transaction fees).

I have read and accept all policies pertaining to refunds and cancellations (missed appointments, no shows, illness, and inclement weather).  I realize I will be charged for non-emergency appointments my child does not attend.

By signing below, I am acknowledging that I understand and accept the cancellation and refund policy.

Notice of Privacy Practice
NOTICE OF HIPPA PRIVACY PRACTICES
Effective May 29, 2018
 
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. PLEASE REVIEW IT CAREFULLY

Your Rights
You have the right to:

Get a copy of your paper or electronic medical record
Correct your paper or electronic medical record
Request confidential communication
Ask us to limit the information we share
Get a list of those with whom we’ve shared your information
Get a copy of this privacy notice
Choose someone to act for you
File a complaint if you believe your privacy rights have been violated
Your Choices
You have some choices in the way that we use and share information as we:

Tell family and friends about your condition
Provide disaster relief
Include you in a hospital directory
Provide mental health care
Market our services and sell your information
Raise funds
Our Uses and Disclosures
We may use and share your information as we:

 Treat you
Run our organization
Bill for your services
Help with public health and safety issues
Do research
Comply with the law
Respond to organ and tissue donation requests
Work with a medical examiner or funeral director
Address workers’ compensation, law enforcement, and other government requests
Respond to lawsuits and legal actions
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record

You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will say “yes” to all reasonable requests.
Ask us to limit what we use or share

You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information

You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated

You can complain if you feel we have violated your rights by contacting us using the information on page 1.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
We will not retaliate against you for filing a complaint.
 

Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

Share information with your family, close friends, or others involved in your care
Share information in a disaster relief situation
Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

Marketing purposes
Sale of your information
Most sharing of psychotherapy notes
In the case of fundraising:

We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures
How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.

Example: We may send evaluations, progress reports and discharge summaries to your primary medical care provider.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your doctor and health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations such as:

Preventing disease
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety
Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities
We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Acknowledgment That You Have Received Our HIPAA Privacy Notice

The Learning Sphere, PLLC is required by law to keep your health information safe. This information may include:

notes from your doctor, teacher, or other health care provider
your medical history
your test results
treatment notes
insurance information
We are required by law to give you a copy of our privacy notice. This notice tells you how your health information may be used and shared. It also tells you how you can look at and comment on your information.

By signing this page, you are saying that you have been given a copy of our privacy notice. 

I acknowledge that there may still be health risks involved in visiting the office and having face-to-face contact with TLS  members. I understand and voluntarily accept those risks and have elected to receive my/my child's speech therapy care in person.

I hereby release and waive any right to bring suit or otherwise make any
claim against TLS in connection with exposure, infection and/or spread of
COVID-19 related to my in-person treatment.

I further acknowledge that if there is resurgence of the virus or if other health concerns arise, including a period of isolation/quarantine for TLS member, she/he/they may choose to return my visits to a virtual format.

In such event, TLS member and I will discuss the reasons for this and make arrangements for continuing care virtually. I understand that I may elect to return to telehealth visits at any time.

If I am diagnosed with COVID-19, I understand and give my consent for TLS to comply with all required notifications to health authorities by providing the minimum necessary information for their data collection. By signing this form, I agree to this without the necessity of any additional release.

This PATIENT ACKNOWLEDGEMENT OF, ACCEPTENCE OF AND INFORMED CONSENT TO POSSIBLE RISKS OF IN-PERSON TREATMENT DURING COVID-19 PUBLIC HEALTH CRISIS supplements the general informed consent and other business agreements I have agreed to with TLS during our work together.