Spoken Word Children's Therapy Forms

Patient Information, Therapy Authorization, and Release Form
Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Start of Care Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address
Referring Physician
Referring Physician's Phone Number:
Format: (000) 000-0000.
Patient's Social Security #
Phone: (home)
Format: (000) 000-0000.
Phone: (work)
Phone: (cell)
Phone: (other)
Caregiver's Name
Caregiver's Relationship
Caregiver's Email address
example@example.com

Primary Insurance Coverage Information Payor:
Payor
Plan Policy #
Group #
Claims Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Phone:
Format: (000) 000-0000.

Policy Holder Information:
Full Name
Relationship to patient
DOB
Employer
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone # (if different than Patient)
Format: (000) 000-0000.

Secondary Insurance Coverage Information Payor:
Payor
Plan Policy#
Group#
Claim's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Format: (000) 000-0000.

Policy Holder Information:
Full Name
Relationship to patient
DOB
Employer
Gender
Address (if different than Patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone # (if different than Patient)
Format: (000) 000-0000.

Patient Financial Responsibility
I understand that I have been referred for therapy services and care with Spoken Word Children's Therapy. I understand that I have the right to ask and have any questions answered prior to receiving any treatment, including any risks or alternatives to the treatment plan that has been prescribed by my physician and/or recommended by my therapist. By signing this agreement, I consent to have Spoken Word Children's Therapy provide treatment and care as prescribed by my physician and/or recommended by my therapist.Any services rendered are charged to the patient and due at the time of service. As a courtesy Spoken Word Children's Therapy will file your claim with your insurance carrier, however the patient or responsible party is ultimately responsible for the charges not covered by your insurance. Any co-payments or deductible amounts not satisfied with your carrier are due at the time of service. It is the patient’s responsibility to understand their insurance coverage.
Patient Name
Patient / Authorized Representative signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Witness
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Patient Cancellation / No-Show Policy

PURPOSE

Your child's success in therapy depends on consistent participation. We are committed to providing exceptional services, and we ask that you partner with us by ensuring your child is ready for their scheduled appointments.

Why Consistency Matters

Regular therapy sessions:
- Build skills progressively over time
- Create a comforting routine for your child
- Foster a strong therapist-child bond for better outcomes
POLICY

Our therapists take therapy sessions seriously, dedicating time to prepare, travel, deliver treatment, and document each session to track progress. Missed appointments will be documented as either a "Cancellation" or "No-Show."

Definitions

No-Show: Patient-initiated cancellation with less than twenty-four (24) hours' notice, or failure to attend a scheduled appointment without providing any notice.

Patient Cancellation: Patient cancels an appointment with more than 24 hours' notice.

Make-Up Appointments: An appointment rescheduled by the therapist that does not count as a cancellation or no-show, as long as the rescheduled appointment occurs.

Excessive Cancellations: A child who misses 15% or more of their scheduled appointments over a 60-day period (excluding make-up appointments).

PROCEDURES

No-Shows / Cancellations:
- Therapists will document missed appointments or cancellations.
- Parent or guardian will be notified of first Excessive Cancellation
- Continued Excessive Cancellations will be evaluated and considered for discharge.
Monitoring Cancellations: Clinic administrators will review cancellation data every 60 days and notify patients if the combined cancellation/no-show rate exceeds 15%.

Patient Discharge Consideration

We understand that unexpected events happen. However, frequent cancellations or no-shows disrupt therapy progress and affect other patients seeking services. In cases of excessive cancellations or no-shows, Spoken Word Children’s Therapy reserves the right to evaluate the patient for discharge from services.
Parent or Legal Representative Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Consent to Release and/or Obtain Information
Patient Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent / Guardian Name
My signature on this form indicates that I (parent or legal representative)
- Authorize the contracted therapists and company representatives to disclose and / or obtain specific health / medical and educational information from the records of the above named child
- Understand that I may request a copy of any information that is disclosed or obtained.
- Agree that a copy of this consent may be treated as an original Understand that if the record contains information relating to HIV infection, AIDS or AIDS-related conditions, alcohol abuse, drug abuse, or genetic testing this disclosure may include that information
- Understand that this information may be released in any of the following ways: fax, email, direct mail, wireless communication or by telephone
- Understand that, while services will not be denied because of failure to sign this consent form, inability to collect necessary information may cause denial of eligibility for Therapy Services with Spoken Word Children's Therapy, Inc.
- Grant consent from the date I sign the consent until discharge of the patient from Spoken Word Children's Therapy, Inc.
- I authorize Spoken Word Children's Therapy, Inc. to use and/or disclose my protected health information to physicians, payers of health care services and other heath care providers to help provide appropriate treatment for my child.
Parent or Legal Representative Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Notice of Privacy Practices

By law, we are required to provide you with our Notice of Privacy Practices (NPP This Notice describes how your medical information may be used and disclosed by us. It also tells you how you can obtain access to this information. As a patient, you have the following rights:

1. The right to inspect and copy your information;

2. The right to request corrections to your information;

3. The right to request that your information be restricted;

4. The right to request confidential communications;

5. The right to a report of disclosures of your information; and 6. The right to a paper copy of this notice should you desire.

We want to assure you that your medical / protected health information is secure with us. This Notice contains information about how we will insure that your information remains private. If you have any questions about this notice, the name and phone number of our contact person as listed on this page: Lauren Ouellette, 850-341-0418

Acknowledgement of Notice of Privacy Practices
This acknowledges that I have received a copy of this practice's Notice of Privacy Practices. I understand that if I have questions or complaints regardingmy privacy rights that I may contact the person listed above. I further understand that the practice will offer the updates to this Notice of Privacy Practices should it be amended.
Patient Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent or Legal Representative Signature
Should be Empty:

Patient Cancellation / No-Show Policy PURPOSE

Patient Cancellation / No-Show Policy

PURPOSE