225 E. Sonterra Blvd, Suite 120
San Antonio TX 78258
Phone: (210) 495-9944 / Fax: (210) 495-2540
PATIENT CASE HISTORY
Does or did your child do these things at an age appropriate level?
EARLY CHILDHOOD INTERVENTION PROGRAM (ECI, Head Start, etc.)
NURSERY / PRESCHOOL
Elementary / Middle / High Scool
PRIOR TREATMENT SERVICES
PREVIOUS TESTING / TREATMENT FOR SPEECH
OTHER FACILITIES THAT HAVE PROVIDED TREATMENT
USE/CONSUMPTION OF FOOD AUTHORIZATION
I hereby authorize the use/consumption of the following foods for therapist guided exercises in speech and oral motor therapy.
PHOTO / AUDIO/ VIDEO / DIGITAL IMAGE RELEASE
I hereby authorize Barbara A. Samfield, MA-CCC/SLP and /or Speech & Language Center at Stone Oak to use:
(Please initial by ALL media approved.)
ASSIGNMENT OF BENEFITS
I request that payment of authorized insurance benefits, be made either to me or on my behalf to the organization listed below for any services provided to me by that organization.
I authorize the release of any medical or other information necessary to determine these benefits or the benefits payable for related services to the organization, insurance carrier or other medical entity.
A copy of this authorization will be sent to my insurance company or other entity if requested. The original authorization will be kept on file by the organization.
I am financially responsible to the Speech & Language Center at Stone Oak for any and all charges not covered by health care benefits. I am responsible for the entire bill or balance for the bill as determined by the organization and/or my health care insurer if the submitted claims or any part of them are denied for payment.
I understand that by signing this form I am accepting financial responsibility as explained above for all payments for services received.
NOTICE OF FINANCIAL RESPONSIBILITIES & INSURANCE POLICIES
If you have any questions about your financial responsibility or our Insurance Policies, please call us at
I attest that the above individual was provided with the above financial responsibility information and this person’s identity was verified by me, the undersigned:
Office Staff Member Signature (SLCSO)
CLINIC CANCELLATION & NO-SHOW POLICY
The Speech & Language Center at Stone Oak strives to offer clients the highest quality professional services available.
An important part of the success of treatment sessions depends on consistency in attendance by patients. When we establish a plan of care, we base our goals on 80% attendance. When appointments are missed, then progress may be impacted and treatment goals may not be achieved as quickly. Missed appointments are also costly to the therapists and this business, and regular attendance helps us keep our costs competitive. We expect that clients will take vacations, and certainly understand that sudden illness and events happen to all of us. In the event that you must cancel, we strongly encourage you to reschedule a make-up in order to maintain current progress.
1. Cancellation notice received by office staff (phone call, voice mail, email) by 7:00 pm CDT/CST day before scheduled appointment OR by 7:00 pm CDT/CST on federal holidays preceding date of appointment
2. First three (3) late cancellations within defined (6) month period* (clients with 1x per week appointments)
3. First six (6) late cancellations within defined (6) month period* (clients with 2x or more per week appointments)
4. Professional staff has to cancel for any reason
*Defined six (6) month period in this clinic are: January 1- June 30 and July 1-December 31
Also, any unused available waived LCA's do not accrue beyond the current six (6) month period.
Please note in the event of severe weather, we will follow the publicly posted closure policies of NEISD. However, cancellation fees will be assessed if the schools and roads are open and weather is fair.
NOTE: Missed appointments remain subject to the Frequent Cancellation Policy (see Frequent Cancellation Policy).
MISSED APPOINTMENT FEES (SPEECH)
$ 36 per missed appointment
MISSED APPOINTMENT FEES (READING / OTHER PROGRAMS)
READING / PREPAID READING / OTHER CLASSES
$ 36 per missed appointment
NOTE: Missed Appointment fees are NOT “Covered Medical Services” and will NOT be billed to insurance. Fees must be paid in full prior to next scheduled appointment.
If you are late to an appointment up to 15 minutes, then we will conclude the session at the scheduled time and the therapist may elect to forego the conference time in lieu of providing direct treatment time. You will be charged and/or insurance will be billed for the full scheduled time.
If you are more than 15 minutes late to an appointment, then we may charge the missed appointment fee and reschedule the appointment.
NOTE: If your therapist is running late for any reason, you will be given your full session time, the option to be seen by another available therapist, or opportunity to reschedule your appointment. We regret any resulting inconvenience to your personal schedule.
FREQUENT CANCELLATION POLICY
Clients may be removed from the regular appointment schedule at the sole discretion of the Business Office or Owner for any of the following reasons:
1. Two (2) consecutive late cancellations without rescheduling and keeping make-up appointments within two weeks of absence
2. Two (2) consecutive “no show” appointments (no noticed received by this office).
3. Frequent cancelled appointments regardless of reason.
4. Less than 80% overall attendance within each defined six (6) month period*
*Defined six (6) month periods in this clinic are: January 1 - June 30 and July 1 - December 31
HOW TO CANCEL
Call or leave a voice message 24/7: (210) 495-9944.
Email cancellation to: Info@stoneoakspeech.com
Voicemail and email messages: Verified by business records.
NOTICE OF PRIVACY PRACTICES
The following notice covers how your health information may be used and disclosed and how you can get access to this information.
Please review this information carefully.
Our Legal Duty
We are required by federal and state law to maintain the privacy of your health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights regarding your health information. We must follow the privacy practices that are described in this notice while it is in effect.
We reserve the right to change our privacy practices, provided such changes are permitted by law. Before any significant changes are made in our privacy practices, we will change this notice and make a new notice available.
You may request a copy of our notice at any time.
Disclosures of Your Health Information
We use and disclose health information about you for the following reasons:
Questions and ComplaintsIf you have questions or complaints regarding your health information please contact:
225 E. Sonterra Blvd., Suite 120 San Antonio, TX 78258
Office: (210) 495-9944 Fax: (210) 495-2540
This form is educational only, and is not intended to be used as legal advice.