Case History

1. CONSENT FOR SERVICES: I authorize About Speech, Speech and Language PLLC, to render therapy services to my child. I understand that care will be provided by an appropraitely trained and licensed health care professional. Treatment can be refused and/or terminated at any time by notifiying About Speech, Speech and Language PLLC in writing. In additon, About Speech, Speech and Language PLLC. may terminate services by notification.
2. AUTHORIZATION TO RELEASE INFORMATION/INSURANCE AGREEMENT: We, at About Speech, Speech and Language PLLC are aware that your child’s speech and language therapy is your main priority. We are also aware that you would like us to bill your insurance company for services rendered by About Speech, Speech and Language PLLC. With this billing option, we will submit your insurance company with any pertinent information (evaluation, treatment goals) needed to complete your insurance forms. If the insurance company denies all or part of your claims filed, therapy services may be put on hold until resolution of insurance billing.
3. NOTIFICATION OF PHYSICIAN OR INSURANCE CHANGES: I agree to notify About Speech, Speech and Language PLLC of any changes in my child’s physician or insurance coverage prior to the date of change.
4. MISSED APPOINTMENTS POLICY: We believe that a consistent schedule is very important to your child progress. If your child misses 3 or more consecutive therapy sessions; our office reserves the right to place your child’s services on hold until the scheduling difficulties are resolved or to discontinue services if necessary.
5. HIPAA NOTIFICATION ACKNOWLEDGEMENT: I have received a copy and reviewed the NOTICE OF PRIVACY PRACTICES from About Speech, Speech and Language PLLC and understand that this agency will comply with all HIPPA regulations.

Dear Parent/Caregiver:

About Speech, Speech and Language PLLC employs Speech-Language Pathology Assistants. The SLPAs will be directly supervised by our Speech-Language Pathologists. The SLP will be responsible for evaluating, establishing treatment plans, and instructing the SLPA on how to implement the treatment goals.

As do many other healthcare professionals, SLPs use SLPAs to implement treatment to their clients. The SLPA is registered with the North Carolina Board of Examiners for Speech-Language Pathologists and Audiologists and is supervised by a North Carolina licensed and ASHA certified Speech-Language Pathologist. Registered SLPAs must have an Associate’s Degree in Speech-Language Pathology Assisting and have passed a competency exam in their field.

Our SLPAs may perform screening tests, provide therapy following a written plan established by the supervising SLP, and assist with scheduling and research activities. The supervision of the SLP involves both direct and indirect supervision of the SLPA.

Please contact the supervising SLP with any questions/concerns regarding your child’s speech-language treatment plan and/or progress in therapy.

About Speech, Speech and Language PLLC Therapy Notice of Privacy Practices

This Notice of Privacy Practices describes how About Speech, Speech and Language PLLC may use and disclose your protected health information. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services. This notice refers to practices followed by our medical and administrative staff, while you are a patient of About Speech, Speech and Language PLLC. Uses and Disclosures of Protected Health

Information

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to physicians or case managers involved in your care, etc. to ensure that the healthcare provider has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining payment for therapy may require that your relevant protected health information be disclosed to the health plan.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support business activities. These activities include, but are not limited to, quality assessment, employee review and training. We may disclose your health information to contractors, agents and other business associates who need the information in order to assist us with obtaining payment or carrying out our business operations. We may use your health information to communicate with you about treatment related benefits that could be of interest to you, to obtain payment for services or to conduct our business operations. However, we do not receive financial remuneration from a third party in exchange for making these communications. We may contact you by phone to schedule appointments or to follow up on our care. It is our policy never to leave vital health care information on voice mail. With your permission, we may share your health information with those you tell us will be helping your child or family member with her/her therapy program.

We may use or disclose your protected health information in the following situations without your authorization: as permitted by the HIPAA Privacy Rule, as required by law, emergencies, abuse or neglect, auditing purposes, research, criminal activity, workers’ compensation, and other required uses and disclosures. About Speech, Speech and Language PLLC. may use or disclose your health information if we have removed information that might identify you.

As an employer-sponsored health plan, we will NOT use or disclose any of your protected health information that contains genetic information that will be used for underwriting purposes. About Speech, Speech and Language PLLC does NOT sell or disclose your protected health information for external marketing or fundraising.

Any uses and disclosures other than those permitted by the HIPAA Privacy Rule will be made only with your written authorization. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time. You may request that we transfer your records to another person or organization by completing a written authorization form.

Rights of the Individual

You have the right to obtain a paper copy of this notice from us even if you have agreed to receive the notice electronically.

We reserve the right to change the terms of this notice at anytime. You may also request a current copy of our notice at any time.

You have the right to inspect and copy your protected health information (fees may apply), whether in paper or electronic format. You have the right to request a restriction of your protected health information – This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. About Speech, Speech and Language PLLC is not required to agree to your requested restriction except if you request that About Speech, Speech and Language PLLC not disclose protected health information to your health plan with respect to healthcare for which you have paid in full out of pocket.

You have the right to request an amendment to your protected health information – If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to request confidential communication from us by alternative means or at an alternative location.

You have the right to receive an accounting of certain disclosures, paper or electronic, except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of the request.

You have the right to receive notice of a breach if your unsecured protected health information has been breached.

You have the right to name a personal representative who may act on your behalf to control the privacy of your health information. Parents and guardians will generally have the right to control privacy of health information of minors unless the minors are permitted by law to act on their own behalf. All requests must be made in writing. About Speech, Speech and Language PLLC will consider all written requests on a case by case basis, but the practice is not legally required to accept them.

Concerns and Complaints

You can complain if you feel we have violated your rights by contacting us at the phone number below. You can file a complaint with the US DHHS OCR by sending a letter to 200 Independence Avenue, SW Washington, DC 20201. We will not retaliate for filing a complaint.

Owner: Jessica Masciarelli Executive | Director: Audra Mescall Email: amescall@aboutspeechnc.com Phone: (919) 938-3824