Authorizations for New Patient

New Patient Authorizations

Pediatric and Adults - all information provided will be kept in strict confidence. By completing all requested information, we will be able to service your needs better.
Patient Name:*

Full NameNickname
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:*

MonthDayYear
SSN of Responsible Payer Party*
Best Contact Number:*
Email:*
example@example.com

Payment

BreatheWorks payment policy is designed to ensure a smooth and convenient experience for patients and reduce barriers and improve access to care.

For insured patients:

BreatheWorks will file insurance claims on behalf of patients.

General payment procedures: A credit/debit/HSA/FSA card must be kept on file. For insured patients, co-pays are charged on the day of service. After insurance claims are processed, an invoice will be sent, and the card on file will be charged 2 days later. *Treatment may be suspended if no payment is received for 30 days.

No-show/late cancellation policy:

A $100 fee applies for missed appointments or $50 for cancellations with less than 48 hours' notice.After three consecutive no-shows, future appointment scheduling may be suspended.

This policy aims to maintain efficient operations while providing flexible payment options for patients.

Collections/ Late fees: If failure to pay your account fee will be applied.

Understanding Your Therapy Session and Billing Codes

During your initial appointment we do an assessment and treatment and typically follow up with weekly treatment sessions, the billing codes we use are based on the specific treatment provided, rather than the time spent. Here are the most common codes and what each code represents:

• 92610 - OMT/Swallowing Assessment, 92522 - Articulation Assessment, 92520/92524 - Voice Assessment, 92523 - Language Assessment

• 92507 – Applied when addressing speech, language, or voice-related goals, such as improving articulation, comprehension, or vocal quality.

• 92526 – Applied when addressing oromyofunctional therapy or swallowing therapy, focusing on oral muscle function and chewing and swallowing techniques.

• 97140 – Indicates manual therapy techniques, including hands-on work to enhance muscle function or reduce tension.

Our Unique Approach

What sets our practice apart is our efficiency and comprehensive treatment approach. We know that your time is important and patient adherence is one, if not the most important key to success. Rather than focusing on one isolated issue for an extended period, we assess the whole patient, uncover underlying causes, and treat at the root level. This allows you to achieve faster, more meaningful, and lasting results—not just symptom management, but real change.

Additionally, we operate from a medical model and strive to accept as many insurance plans as possible.

Our mission is to reduce barriers to care and ensure greater access to high-quality treatment for all patients. We are deeply committed to delivering effective, long-term solutions that make a real difference in your life. If you have any questions about your treatment or billing codes, we’re always happy to provide further clarification. Your care is our priority, and we are here to support you every step of the way.
Insurance
ID:

Insured IDGroup Number
Insurance:

CompanyGroup Name
Primary Insured:

Full NameDate of Birth
Photos of Insurance Cards Front and Back:*

Cancelof
Photo of the Front of Responsible Party's Drivers License:*

Cancelof
Secondary Insurance:
Insurance, Member ID, Group, Contact
Insurance & Financial Responsibility Disclaimer
As a courtesy, we make every effort to verify your insurance benefits prior to your appointment. However, insurance information provided to us by your carrier may be incomplete, outdated, or inaccurate. Because of this, any information we share with you regarding coverage is only an estimate and not a guarantee of payment.

Please note that you are ultimately responsible for all charges incurred, including deductibles, co-pays, co-insurance, and any services not covered by your plan. We strongly encourage you to contact your insurance provider directly to confirm the specific details of your coverage and financial responsibility.

By signing below, you acknowledge that you understand and accept these terms.

I hereby authorize the healthcare provider to:
- Submit insurance claims on my behalf for medical services rendered
- Charge the credit card currently on file for any patient financial responsibilities, including but not limited to copayments, deductibles, and coinsurance
I have read, understand, and agree to all the above terms of the BreatheWorks payment policy and to submit claims on my behalf to my insurance.*

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I have read and consent to patient communication consent.*

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Date*

MonthDayYear
Date
Patient Communication Consent & Photo Policy
At BreatheWorks, we value collaborative communication among all members of a patient’s care team, as it plays a vital role in enhancing the effectiveness of assessment and treatment outcomes.
I authorize BreatheWorks permission to:*

Release recordsObtain recordsVerbally communicate withNone of the above
Please list all providers, including your referring provider and primary care provider, who you give us consent to communicate with. *
Recurring Message Terms and Conditions
Effective Date: Jan 1, 2024

By opting in to receive SMS messages from BreatheWorks Speech Therapy (“we,” “us,” “our”), you agree to these Terms and Conditions ("Terms").

SMS Messaging Service
By providing your mobile phone number, you consent to receive recurring SMS (text) messages from BreatheWorks Speech Therapy for purposes including but not limited to:
- Appointment reminders and confirmations
- Rescheduling and cancellation notifications
- Notifications of clinician absences or clinic closures
- Requests for updated insurance or contact information
- Balance due and billing-related alerts
- To stop receiving SMS messages from BreatheWorks, reply STOP to any message. For assistance or more information, reply HELP to any message. *Please note that for appointment confirmations reminders it will be a requirement to receive treatment to confirm by phone call. If the appointment is not confirmed it will be canceled and you will be called to reschedule your appointment.
Message and data rates may apply. Please contact your mobile carrier for details.

Message Frequency
BreatheWorks may send you conversational messages related to your use of our services. Message frequency may vary, with an average of 2-8 messages per month. By providing your phone number, you consent to receive these messages. Standard message and data rates may appl
Photography Use and Consent

At BreatheWorks, we use photographs as part of our clinical documentation to assess and track oropharyngeal structural and functional characteristics—including posture, craniofacial shape, dentition, tongue position, lip seal, and soft palate function—as well as to monitor patient progress over time.

In addition to clinical use, select photographs may be used for internal training and professional education purposes. Please indicate your photo release preferences below.
Photo Utilization Release: I grant permission to BreatheWorks to use*

Clinical Photographs Only (for report generation and baseline)Clinical and Educational PurposesAll: This authorization includes the right to reproduce, distribute, and publicly display the forms in various media formats.Other
I have read and consent to the communication and photo policy.*

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Patient Appointment Policy

At BreatheWorks/Speechworks, we value your time and are committed to providing high-quality care during your scheduled treatment appointment in person and over teletherapy. To ensure effective communication and optimal clinical outcomes, please adhere to the following scheduling guidelines:

Confirming Appointments:
All appointments must be confirmed 2 business days before they are scheduled to begin. Appointments can be confirmed via email, text, voicemail, or speaking with our scheduling team. In order to make confirming as convenient as possible, all patients will receive a text reminder 3 business days before their scheduled appointment, and we will follow up with a phone call if we have not received confirmation by the next day. If we still have not received confirmation, by the end of our business day, 6:00pm, 48 hours before your appointment, we will cancel your appointment and our schedulers will call you to reschedule.

Arrival Time:
For In-Person Treatments, please arrive at our office 10 minutes ahead of your scheduled appointment time.
For Virtual Sessions, please log in and join the meeting 5 minutes before your scheduled appointment time. Additionally, please ensure that your camera and mic are operational, that you have a light source in front of you, and that you have water in an open cup.

Rescheduling or Cancellation:
If you need to reschedule or cancel your appointment, please provide at least 48 hours notice so we can accommodate other patients. Cancelling less than 48 hours before the appointment may result in a Late Cancel Fee.

Communication:
Please contact us with any questions or concerns.
You can text or call us at (971) 346-0355, or email us at info@breatheworks.com
I have read and consent to the appointment policy*

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Acknowledgement of HIPAA Privacy Practices

Authorization: I authorize the use and disclosure of my protected health information for treatment, payment, and healthcare operations. I also authorize BreatheWorks to take photographs or videos for clinical purposes, such as documenting progress, treatment planning, and educational purposes. These images will be used strictly within the scope of your medical care and protected under HIPAA regulations to ensure your privacy and confidentiality.

Understanding: I understand I have the right to request restrictions on how my information is used and disclosed and to revoke this authorization at any time except where action has already been taken.

Consent for Treatment: I consent to receive treatment from BreatheWorks/SpeechWorks and its healthcare providers.

Uses and Disclosures of PHI: Without your written authorization, we may use and disclose your PHI for treatment, payment, and healthcare operations. Other uses and disclosures may occur for public health activities, law enforcement, and judicial proceedings.

Your Rights: You have the right to request restrictions on specific uses and disclosures of your PHI, access and obtain copies of your PHI, request amendments to your PHI, and receive an account of disclosures of your PHI in our "HIPAA Authorization Form."

Our Responsibilities: We are required by law to maintain the privacy of your PHI, provide you with this Notice of Privacy Practices, and abide by the terms outlined in this notice.

Contact Information: If you have questions, or concerns about our privacy practices, or to exercise your rights, please contact our practice at 971-346-0355.

Changes to this Notice: We reserve the right to change the terms of this Notice of Privacy Practices and will provide you with a revised notice upon request.
I acknowledge that I have received a copy of the Notice of Privacy Practices and understand that I have the right to review it before signing this form.*
Name of Person Completing Form and relationship to patient (if applicable): *

Full NameRelationship to patient
I have read and consent to the Acknowledgement of HIPAA Privacy Practices*

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Date*

MonthDayYear
Date
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New Patient Authorizations

Patient Communication Consent & Photo Policy