Payment Policy

• Payment for services is due at the time services are rendered.
• There are no refunds for services rendered.
• There is a $ 25.00 fee for any check returned.

Cancellation Policy

• Except for emergencies, all cancellations must be made 24 hours in advance of your scheduled appointment.
• Private clients and clients paying through insurance will be charged a $ 35.00 fee for the second canceled or missed visit and for any visits subsequently improperly canceled or missed visit.
• Due to unforeseen circumstances (e.g. therapist’s daytime school schedules; summer, school holidays, and breaks) scheduling changes may occur that also may contribute to therapist changes.
• I understand that I am financially responsible for all charges regardless of insurance coverage or treatment outcome.
• I understand that I will be charged for any appointment missed or canceled with less than 24 hours’ notice, as explained above. I hereby agree to pay any and all charges for services rendered.
• I understand that I must immediately notify the Center of any health insurance changes or disruptions in coverage, and that if I fail to do so, I am responsible for full reimbursement of services provided.

THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO YOUR INFORMATION. PLEASE REVIEW CAREFULLY THE FOLLOWING.

OUR COMMITMENT TO PRIVACY

At All in 1 SPOT (the “Center”), we understand that the personal health information about you and your family is private. The Center is required by law to maintain the privacy and security of your protected health information. The Center promptly will notify you in the event that a breach has occurred which may have compromised the privacy or security of your information.

Use and Disclosure of Protected Health Information

In the course of treating an individual, a health care provider collects or otherwise obtains an individual’s family medical history. This information becomes part of the individual’s medical record and is treated as “protected health information” about the individual. This information is shared only on a need-to-know basis with those who participate in the care of the patient. Personal health information is not shared with anyone else without the patient’s written authorization. No persons or agencies will have access to information about you and your treatment without your written permission. The following notice describes how medical information about the patient/client may be used and disclosed and how the patient/client can get access to this information. Please review it carefully.

Permitted Disclosures

Treatment, payment, and health care operations

The HIPAA Privacy Rule allows health care providers to use or disclose protected health information (other than psychotherapy notes), including family history information, for treatment, payment, and health care operation purposes without obtaining the individual’s written authorization or other agreement.

The Center uses health information about you to manage your treatment and services. For instance, your health information may be used and shared with other professionals who are treating you, such as when a doctor treating you for an injury asks your other doctor about your overall health condition. Health information may be used and shared to operate the Center’s practice, improve your case, and contact you when necessary. Such uses of your health information may include, but are not limited to, exchanges for the purpose of conducting quality assessment and improvement reviews or developing clinical guidelines and protocols. Health information also is used and shared to bill and collect payment from health plans or other entities. Thus, the Center will give to your health insurance provider information about you so that it will pay for your services or when necessary to certify the patient/client’s eligibility for certain benefits, such as workers’ compensation.

Patient/Client Emergencies

Information may be used and disclosed in emergency situations, in circumstances where there is no opportunity to obtain the patient/client’s informed consent, such as during the patient/client’s incapacity. 

Consultation with other professionals

Best practice often involves consultation with other professionals to ensure the provision of quality care. Service providers may seek from the patient/client informed consent to permit personally identifiable information to be revealed to a consulting professional. In the absence of such consent, service providers will disguise the information before sharing it with a consulting professional so that the patient/client cannot be identified.

Public health activities

The Rule also generally allows disclosure without prior written authorization for certain purposes to benefit the public, for example, circumstances that involve public health research or health oversight activities. Such circumstances may include, but are not limited to, exchanges for the purpose of reporting disease, conducting public health surveillance, reporting adverse reactions to medications, or preventing or reducing a serious threat to the health or safety of any person.

Other government requests

The Center may use and share your health information for special government functions, such as military, national security, and presidential protective orders.

Required Disclosures

Comply with the law

Personal health information will be used and disclosed by the Center if required by federal, state, or local laws, including with U.S. Department of Health and Human Services, New York State Office of Mental Hygiene, and Office of Professional Discipline where the entity seeks to ensure compliance with any law, rule, or regulation.

Respond to legal or administrative proceedings

The Center may share and use your health information in response to a court or administrative order, or in response to a subpoena or other legal process, and to defend against any claim asserted by the patient/client against the Center or service providers.

Individuals’ Right to Access their Health Information

Get an electronic or paper copy of your medical record

Upon request, you may obtain a copy of your medical record and other health information that the Center has about you. A copy or a summary of your health information will be provided, usually within 30 days, for a reasonable, cost-based fee.

Correct your medical record

You may request that the Center correct health information about you that you believe is incorrect or incomplete. If the request is denied, the Center will state in writing, usually within 60 days,  the reasons why the request has been denied.

Request confidential communications

You may ask the Center to contact you by specific means, such as by home or office phone, or to send mail to a different address, and the Center will comply with all reasonable requests.

Ask us to limit what we use or share

You may ask the Center not to use or share certain health information for treatment, payment, or our operations. However, the Center is not required to comply with such a request, and it will not comply if the Center believes that it would or could affect the patient/client’s care.

If you pay out-of-pocket, in full, for a service or health care item, you may ask the Center not to share with your health insurer that information for the purpose of payment or our operations. The Center will comply with any such request unless the Center is required by law to share such information.

Get an accounting of those with whom we have shared your information

You may request a list, or an accounting, of the times that the Center has shared your health information, with whom the Center has shared it, and why, for six years prior to the date of your request. The Center will list all disclosures it made, except for those internal disclosures about treatment, payment, and health care operations, and certain other disclosures, such as any disclosures that you asked the Center to make. The Center will provide for free one accounting per year, and will charge a reasonable, cost-based fee for any additional requests made within 12 months.

Get a copy of this privacy notice

You may at any time request to obtain a paper copy of this notice, even if you have agreed to receive the notice electronically. The Center promptly will provide you with a paper copy.

Choose someone to act for you

If you have given someone medical power of attorney or if you have a legal guardian, that person may exercise your rights and make choices about your health information. The Center will ensure that the person has this authority and can act for you before the Center takes any action.

Changes to the Terms of This Notice

The Center has the right at any time to change the terms of this notice, and all changes will apply to all information that the Center has about you. A copy of the new notice will be available to you upon request, in our office, and on our website.

Complaints

A person who believes that the Center is not complying with these privacy practices may file with the Office Manager a written complaint.

For Additional Information

If you have any questions or concerns about this Notice of privacy practices, you may contact the Office Manager at (718) 767-0071/0091.

Authorization for Use and/or Disclosure of Protected Health Information

I, or my authorized representative, hereby authorize the use and/or disclosure of my protected health information as described below.

ALL IN 1 SPOT WITH THERATALK is required by law to protect your health information. I understand that the recipient(s) of my health information may not be required by federal privacy laws to protect it and may be permitted by law to share with others my health information without my permission. I understand that once my health information is disclosed, ALL IN 1 SPOT WITH THERATALK is not responsible for ensuring that any recipient(s) of my health information will use and/or disclose the information for the purpose(s) described in this authorization.

The name and birthdate of the Patient/Client whose protected health information is the subject of this authorization, and the name of his or her authorized representative, if any:

A. Purpose of this form
If you, or your authorized representative, sign this document, you give permission to the health care providers at ALL IN 1 SPOT WITH THERATALK to use and/or disclose (release) your patient information for the following purpose(s):

B. Information to be used and/or disclosed and to whom
“Patient information” means the health information in your medical or other healthcare records, including identifying information, such as your name, address, phone number, and birthdate. The health information that may be used and/or disclosed for the purpose(s) stated above includes:

The health information listed above may be used by and/or disclosed (released) to the following recipient(s):

This authorization is valid for the following time period:

C. Voluntary and revocable authorization 
I understand that this authorization is voluntary and that I may refuse to sign it. No individual has coerced me into signing this authorization, and I, or my authorized representative, am providing this authorization under my own free will. I acknowledge that I, or my authorized representative, have the right at any time to revoke this authorization, except to the extent that your health information already was disclosed pursuant to this authorization. I further acknowledge that any such revocation must be in writing sent to the Office Manager at ALL IN 1 SPOT WITH THERATALK at 150-50 14th Road, Whitestone, NY 11357.

D. Treatment, payment, enrollment and eligibility for benefits are not conditioned on the execution of this authorization

I understand that ALL IN 1 SPOT WITH THERATALK may not condition treatment, payment, enrollment or eligibility for benefits on my, or my authorized representative’s, execution of this authorization. 

E. Signature
By signing below, I acknowledge and affirm the truth of the statements made in this, and that I, or my authorized representative, have received a signed copy of this authorization form.

Welcome! We are glad that you chose our facility for speech/physical/occupational therapy services. Our staff understands that you are entrusting us to provide you or your loved one with optimal therapeutic care. Our goal is to respect and honor all of our patients/clients and their families as we work together. To make this possible, we inform you below of the policies and procedures to be followed in this office.

Attendance/General Procedures

• Once you arrive at the clinic, always check in with the office manager at the front desk.
• If your child is ill and has difficulty participating in normal daily routines, you must notify this office to cancel the session. Children who are ill do not benefit from therapeutic intervention.
• All cancellations must be made 24-hours in advance whenever possible. If your child becomes ill on the same day as your session, you must call by 9 AM to notify this office and reschedule the session.
• Cancellations made after the required time will not be rescheduled for a make-up session.
• Late cancellations and failures to show up at a scheduled session will not be made up and may be billed to the parent paying privately. This policy does not apply to patients receiving services pursuant to a Department of Education mandate. 
• If you suspect that your child cannot attend a scheduled session, please CALL IMMEDIATELY to inform the therapist. DO NOT WAIT UNTIL THE LAST MINUTE. For instance, if your child is sick on Monday, and may not be able to attend a session scheduled on Tuesday morning, DO NOT WAIT until Tuesday morning to inform the therapist. 
• NO-SHOWS ARE UNACCEPTABLE. There will be NO MAKE-UP SESSIONS for no-shows. 
• Excessive absences or cancellations without prior notification may result in termination of services.

Consistent and timely attendance is necessary for your child’s progress. If you miss three consecutive sessions, without providing 24-hours’ notice, or if you otherwise frequently cancel scheduled sessions, your appointment time is not guaranteed.

• For private-paying patients/clients, sessions that are canceled without 24-hours’ notice must be paid in full.
• Parents are welcome to observe their child’s session, so long notice is given prior to the session to be observed.
• It is our preference that siblings do not accompany parents in observations, as it may distract the patient.
• Siblings always are welcome in the waiting area with parent supervision. 
• For safety reasons, siblings should not be left unattended in the waiting area or anywhere else.
• You, or a designated caregiver at least 18-years old, must sign the therapist’s attendance form. 
• If a session must be rescheduled, it should not be assumed that the same time requested or the same therapist assigned (excluding DOE) will be available to render services.
• All patients should check in at the front desk as soon as they arrive and provide payment for that session.
• All payments for private sessions and co-pays must be paid at the beginning of each treatment session.

For Pediatric Patients

Make-up sessions

• Make-up sessions can be given only pursuant to the mandate.
• Sessions are not billed before they are performed, to be used later for make-ups. Sessions are billed as they are performed. 
• If you miss a session, your therapist may provide make-up sessions on a make-up day or during a holiday week, i.e., Christmas week, February break, and/or Spring break.
• There is no guarantee that all sessions will be made up.
• Missed sessions may be rescheduled during legal holidays if the therapist’s schedule permits. If your child misses his or her session secondary to their Annual Review meeting, a make-up session will be provided if the therapist’s schedule permits. 

Therapy specifics

• No services can begin until we receive a copy of your child’s most recent IEP/Evaluation, RSA-2 Form/CPSE signed contract, DOE transmittal.
• Discussion of your child’s progress is considered part of the therapy process. Therefore, all therapy sessions will allow for direct intervention and parent/guardian consultation within the allotted therapy time. 
• Occupational and physical therapy cannot begin until a doctor’s prescription is obtained. 
• All parents must read and sign the included HIPAA form.
• Please be respectful of therapy sessions that are scheduled immediately after your appointment and of the therapist’s busy schedule by using the last five (5) minutes of the therapy session to ask all questions and voice all concerns. If more than five (5) minutes is needed for discussion, please request more time with the therapist at the beginning of the treatment session. Therapy sessions scheduled at intervals of 30, 45, or 60 minutes cannot exceed that time. 
• Do not enter therapy suites until the therapist comes out to take your child.
• Observations of treatment sessions are allowed by appointment only. Please see the office manager regarding the scheduling of observations. 
• All written reports (e.g. progress reports, IEP goals, etc.) require at least two (2) weeks prior notice. Please understand that reports requested by parents cannot be completed in less than two (2) weeks.

Sensory Gym

• The suspended equipment in the sensory gym is dangerous if used improperly. Only children scheduled for treatment in the sensory gym may be present in the sensory gym and must be with their therapist. No food or drink is permitted in the sensory gym.

Waiting Room

• Please do not leave any children unattended in the waiting room.
• You, or a designated caregiver, must be accessible or reachable by phone while your child is receiving services, and you must be present in the waiting room at least 10 minutes before the end of the session.
• Parents or patients without a cell phone must be present in the waiting room until the end of the session.
• You must provide to the office manager emergency contact information and a cell phone number prior to leaving your child at a session.
• Please be aware that the last five (5) minutes of treatment sessions are dedicated for discussion of session results, progress, and carryover.
• Please silence all cell phones and use quiet voices when entering and while inside the building. Please be respectful as there are other offices in the building.
• Please be observant of your child and siblings in the waiting room. Your help in keeping the area clean is greatly appreciated. Please keep the center of the waiting room clear to allow traffic in and out.
• Please be respectful of the other individuals receiving treatment from the Center. Avoid using last names and asking questions regarding other patients’ identities. Confidentiality for all individuals receiving services is of the utmost importance to us.

Confidentiality 

• We cannot share information about a child or other patient outside of the clinic without the parent’s or patient’s consent. We are authorized to discuss a child’s or patient’s diagnosis, session, and behavior with the child’s parent’s or authorized caregiver, the patient or authorized representative, and with other members of the child’s or patient’s care team.
• We will discuss you or your child’s session at the end of the session. These discussions should not occur in the hallways in order to maintain confidentiality.
• Please do not wander or wait, or allow children to wander or wait, outside the room where the session is occurring. Other children and patients are receiving services and must remain confidential. 
• Parents may observe treatment conducted in the sensory gym, but protected health information will not be shared with anyone. If you do not wish your child to be observed in the sensory gym, please submit a written request to the directors. 

Cancellations and No-Show Policy

We understand that there are times when you must cancel an appointment due to illness or other emergencies or obligations. However, when you do not call to cancel an appointment, you may prevent another patient from receiving the therapy they need. Conversely, there are times when a parent or patient fails to cancel a missed appointment and we may be unable to schedule you for a visit, due to the appearance of a full schedule. 

• In order to be respectful of the therapeutic needs of other patients, please be courteous and promptly call if you are unable to appear for a scheduled session.
• If a session is not canceled at least 24 hours in advance, you will be charged a $35.00 fee, and this fee will not be covered by your insurance plan.
• Failures to show up for a scheduled appointment and late cancellations are recorded in your record. 
• For the first missed appointment, there is no charge.
• For the second missed appointment, a $35.00 fee will be billed to your account.
• For the third missed appointment, an additional $35.00 fee will be billed to your account and you will be discharged from our practice. 

Allergies/Medical Conditions

• It is your responsibility to notify the therapist of any allergies or medical conditions experienced by the Patient/Client in formal writing to this email address: theratalk@allin1spot.net.
• If there is any change in the Patient/Client’s medical status, we must be provided with written clearance from the Patient/Client’s physician before the Patient/Client can return to therapy. We also need an updated prescription in order for the Patient/Client to return to therapy. 

FAILURE TO COMPLY WITH ANY OF THESE POLICIES AND PROCEDURES MAY LEAD TO THE TERMINATION OF SERVICES BY THE CLINIC.

Please sign below to indicate that you have read and you understand each policy and procedure stated herein. Thank you.

IT IS CRUCIAL TO US TO PROVIDE THE HIGHEST LEVEL OF SERVICE TO OUR FAMILIES. PLEASE KNOW THAT WE ARE ALWAYS HERE TO HELP AND TO SPEAK TO IF THERE ARE ANY ISSUES/CONCERNS.  PLEASE EMAIL US WITH ANY CONCERNS YOU MAY EVER HAVE:  THERATALK@ALLIN1SPOT.NET

It is our intent to provide the Patient/Client with services of the highest quality. We understand that disagreements may arise and may not be immediately resolvable between the parties. The Clinic has implemented a three-step process designed to amicably resolve any and all disputes arising out of the relationship among the Patient/Client, and any third-party beneficiaries, and the Clinic and its health care providers. The process begins with a simple discussion, or a preliminary negotiation, among the parties involved to solve the problem by agreement. If negotiations are unsuccessful, the parties may at their option engage an outside third party to mediate the parties’ compromise on a mutually agreeable solution. If the mediation fails, the parties may commence legal action either under the New York Simplified Procedure for Court Determination of Disputes or by a bench trial as described below.

Step One: Preliminary Negotiation

• The first step in the dispute resolution process is a face-to-face discussion of the issue among the parties involved so that they may solve the problem directly by agreement.
• The parties shall engage in good faith negotiations by consulting with one another to identify their shared interests and determine a mutually agreeable outcome. To achieve a just and equitable solution, the parties will communicate honestly and try sincerely, without unfair advantage, to agree on a solution. The preliminary negotiation stage will cease after a period of 60 days unless all parties agree to continue in the negotiations. 
• If the parties are able to negotiate a resolution within a period of 60 days, such resolution shall be final and binding upon and enforceable by the parties.

Step Two: Optional Intermediary Mediation

• If the dispute cannot be resolved by a negotiated agreement of the parties, then the parties may agree to seek the assistance of a neutral third party, mutually selected by the disputing parties, to act as a mediator and facilitate a compromise among the parties in an effort to reach a voluntary settlement. 
• Upon notice by any party involved, the parties shall select a neutral mediator and engage in good faith in the mediation process by acknowledging each other’s respective interests and compromising on a satisfactory resolution. The Intermediary Mediation stage will cease after a period of 60 days unless all parties agree to continue the mediation.
• If the dispute cannot be resolved by voluntary settlement after mediation, any party may resort to litigation pursuant to the procedures set forth below.

Step Three: The New York Simplified Procedure for Court Determination of Disputes or Bench Trial

• The parties may commence a legal action by the filing in a court of appropriate jurisdiction a statement pursuant to the procedures set forth in Civil Practice Law and Rules (CPLR) §§ 3031 et seq. or New York City Civil Court Act § 901.
• THE SUBMISSION OF A CONTROVERSY UNDER THE NEW YORK SIMPLIFIED PROCEDURE FOR COURT DETERMINATION OF DISPUTES SHALL CONSTITUTE A WAIVER BY THE PARTIES OF THE RIGHT TO A TRIAL BY JURY.
• The execution of this agreement shall be construed as consent by the parties to the jurisdiction of the supreme court of New York State to enforce it pursuant to the procedures of CPLR rule 3036, and to enter judgment thereon, and shall constitute a waiver by the parties of the right to a jury trial.
• In the event that a court of appropriate jurisdiction determines for any reason that the particular dispute is not eligible for or subject to adjudication under the New York Simplified Procedure for Court Determination of Disputes, then the parties hereby agree to submit to a bench trial before the Court.
• THE SUBMISSION OF THE PARTIES TO A BENCH TRIAL SHALL CONSTITUTE A WAIVER BY THE PARTIES OF THE RIGHT TO A TRIAL BY JURY.
• The execution of this agreement shall be construed as consent by the parties to an adjudication by bench trial before the Court, and shall constitute a waiver by the parties of the right to a jury trial.

Statute of Limitations

To the extent allowed by law, the statute of limitations applicable to the claim(s) that is the subject of the parties’ dispute shall be tolled during the time during which the parties are engaged in step one preliminary negotiations and any step two intermediate mediation.

Provisional Relief

Notwithstanding any language herein to the contrary, without waiving any right or remedy provided under this agreement, any party may at any time seek from a court of appropriate jurisdiction injunctive or other provisional relief necessary to protect the rights, reputation, or property of any party until such time as the parties’ dispute may be finally resolved.

Please sign below to indicate that you have read and you understand each and every terms of the dispute resolution process and procedures.