Financial Policy 

Thank you for choosing For Goodness Speech, LLC! Please note that For Goodness Speech, LLC is an out-of-network provider and does not directly work with insurance companies. We do provide documentation if requested for reimbursement by your insurance. Clients are responsible for confirming insurance coverage and handling all reimbursement. Please note that all insurance companies vary and speech-language services may or may not be covered by insurance. If you have Husky insurance, private pay services are NOT typically reimbursed. Session fees are as follows:

Initial evaluation: $325-$450

30 min session: $85

45 min session: $105

1 hour session: $130

Co-treat with Occupational Therapist (45 minutes only): $85

All payment for services is required at the time services are rendered. 

We accept payment by personal check at the time of service. There is a service charge of $25.00 for any returned check. We also accept credit card /HSA. Billing is completed by IvyPay. On the day of evaluation, you will be sent a text message from IvyPay to set up your account. The card you set up your account with will remain on file and be charged automatically on the day of your therapy session. 

 

Please initial below:

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. HIPAA provides penalties for covered entities that misuse personal health information. 

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information

Treatment means providing, coordinating, or managing health care and related services, by one or more healthcare providers. An example of this would include a physical examination.

 

Payment means such activities as obtaining reimbursements for services, confirming coverage, billing or collections activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.

Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review. 

We may create and distribute de-identified health information by removing all references to individually identifiable information. 

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you, 

 Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. 

You have the following rights with respect to your protected health information which you can exercise by presenting a written request to the Privacy Officer:

The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosure to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to the requested restrictions. If we do agree to restrictions, we must abide by it unless you agree in writing to remove it. 

The right reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.

The right to inspect and copy your protected health information. The right to amend your protected health information. The right to obtain a paper copy of this notice from us upon request. 

This notice is effective as of April 14, 2003, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health and Human Services, Office of Civil Rights, about violations of the provision of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint. 

Please contact the following for more information: 

The U.S Department of Health & Human Services Office of Civil Rights 200 Independence Avenue, S.W. Washington D.C. 20201 (202) 619-0257 Toll free: 1-877-696-67

 

 

 

 

For Goodness Speech, LLC is required by law to keep your health information and records safe.

This information may include :

• Notes from your doctor, teacher, or other healthcare providers
• Medical history
• 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. 

I acknowledge that I have received a copy of For Goodness Speech, LLC's HIPAA Notice of Privacy that fully explains the uses and disclosure they will make with respect to my individually identifiable health information.

I have had the opportunity to read the notice and to have any questions regarding the notice answered to my satisfaction. 

I understand that For Goodness Speech, LLC cannot disclose my health information other than as specified in the notice

I understand For Goodness Speech, LLC reserves the right to change the notice and the practices detailed therein if it sends a copy of the revised notice to the address I have provided. 

 

The American Speech Language and Hearing Association (ASHA) defines telepractice (the act of providing Telehealth services) as "the application of telecommunications technology to delivery of professional services at a distance by linking clinician to client, or clinician to clinician, for assessment, intervention, and/or consultation." This service delivery model is supported by the Connecticut licensing board and the American Speech-Language and Hearing Association (ASHA). Telepractice is viewed as a mode of delivery of health care services, not a separate form of practice. There are no legal prohibitions to using technology in the practice of speech language pathology, as long as, the practice is done by a Connecticut licensed practitioner or a practitioner that is also licensed in the state in which the client is receiving services. The standard of care is the same whether the patient is seen in person or through telepractice. For Goodness Speech, LLC offers telepractice speech and language services through Google Meets and the Presence Learning platform. Our business agreement with the Google Meets and Presence Learning platform incorporates software security measures that meet HIPPA standards. This is in place to protect the confidentiality of patient identification and data and protect against intentional or unintentional corruption.

 

1. I understand that “telepractice” includes diagnosis and treatment using interactive audio, video, or data communications. I understand that telepractice also involves the communication of my medical information, both orally and visually.

2. I understand that the standard of care is the same whether the client is seen in person or through telepractice and that I will be notified immediately if it is determined that this delivery model is not appropriate for a client.

3. I have the right to withhold or withdraw consent to participate in telepractice at any time without it affecting my right to future care or treatment.

4.  I understand that I am responsible for providing the necessary computer, telecommunications equipment (camera and microphone), and internet access for my telepractice sessions.

5.  I understand that for certain clients, an adult facilitator will be required to be present in the room for assisting with technical difficulties or keeping a client on task.

6. I understand that I am responsible for arranging a quiet location with sufficient lighting and privacy that is free from distractions or intrusions for the telepractice session to take place in.

7. I understand that For Goodness Speech’s “payment policy” is the same for telepractice appointments as in-person appointments. The client is responsible for the payment of all services rendered.

8.  I understand that there are benefits, risks, and possible consequences associated with telepractice, including, but not limited to, the possibility, despite reasonable efforts on the part of For Goodness Speech, LLC, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.

 

I have read and understand the information provided above and have had my questions answered to my satisfaction.

I have read this document carefully, and understand the risks, benefits, and rights related to telepractice and I am hereby electively giving my informed consent to participate in a telepractice service through For Goodness Speech, LLC under the terms described herein.