New Client Form

Welcome to Innovative Speech & Language Pathology, Inc.

Our words are the breath that vibrates through the body and gives life to our intentions. This vibration is the binding force among individuals. ~Odelia Mirzadeh (Director of ISLP, Inc.)

Thank you for choosing ISLP, Inc. to help meet your child’s communication needs. We realize there are many options from which to choose and we appreciate the opportunity to assist you with this important process. At ISLP, Inc. we strive to help our clients achieve their highest potential and are honored to be part of each of our client’s lives.

The attached new client paperwork packet includes important information about ISLP, Inc. including insurance, financials, privacy policies and cancellation policies. We appreciate you taking the time to complete the necessary information as best as you can since this information can be vital to the direction of the therapy plan. We suggest that you turn in the completed packet prior to our initial meeting in an attempt to save time reviewing this information on the day of and so we can provide the best possible service for you and/or your child. If you or your child have any recent evaluations completed by other health professionals (psychologist, IEP, etc.), please bring copies of these documents with you or mail them to ISLP, Inc. in advance.

Please feel free to contact us via phone or e-mail with any questions or concerns at islp@innovativeslp.com or call us at 310-659-9511.

We look forward to meeting you and your child soon.

Best,


Odelia Mirzadeh, M.S., CCC-SLP
8665 Wilshire Blvd. Ste.#412,
Beverly Hills, CA 90211
E: Odelia@innovativeslp.com
www.innovativeslp.com

Client Initial Intake Form

Client's Name:

Address:

Home phone:

Work phone:

Client date of birth:

Sex:

Marital Status:

Client's occupation:

Place of employment:

Spouse's name:

Spouse's phone:

General physician/Pediatrician:

IF MINOR

Mother's name:

Father's name:

Mother's cell:

Father's cell:

Siblings' names:

Client's grade in school:

Address and phone number of school:

Person responsible for payment:

Who can we thank for their kind referral:

Insured Information

Insured's name:

Date of birth:

Insured's address (if different from client):

Insured's Social Security Number:

E-mail address:

Employer name and address:

Insurance Company:

Policy #:

Group #:

Insurance phone:

Insurance address:

Do you have a secondary policy? If so please list:

PLEASE NOTE: If appointments are not cancelled at least 24 hours in advance, you will be billed for the time reserved for you. Payment for all professional services are due in full at the time of service unless prior payment arrangements have been made. Please refer to ISLP, Inc.’s cancellation for further details. Accepted forms of payment are cash, check and/or credit card (Master Card, Visa, American Express, Discover Card).

Client's name:

Parent/guardian name if minor:

Client's signature:

Parent/guardian signature:

Cancellation Policy/Financial Responsibility

Thank you for choosing Innovative Speech & Language Pathology, Inc. (ISLP), as your healthcare provider. The services you seek imply an obligation on your part to ensure payment in full is made for services received. This Client Financial Responsibility Statement (“Statement”) will assist you in understanding that financial responsibility. If someone else (parent, spouse, domestic partner, etc.) is financially responsible for your expenses or carries your insurance, please share this Statement with them, as it explains our practices regarding insurance billing, copayments, and Client billing. By your acknowledgment of this Statement and/or by receipt of medical services from Innovative Speech & Language Pathology, Inc., you agree:

When payment is due:
Payment in full is due at time of service. You may pay by cash, check, or credit card. Delinquent accounts past 30 days are subject to late fee penalty charges as described below and will result in termination of further sessions until the outstanding balance has been cleared. We deeply appreciate your efforts to stay current with your payments.

Insurance:

  1. You acknowledge and agree to all financial policies of ISLP. Questions about these policies may be addressed to the front desk staff and the office manager. These policies may be changed from time to time by ISLP, without notice. If there is any conflict between the financial policies and this Client financial responsibility statement, the financial policies shall control.
  2. You are ultimately responsible for all payment obligations arising out of your treatment or care and guarantee payment for these services. You are responsible for deductibles, co-payments, co- insurance amounts or any other Client responsibility indicated by your insurance carrier or our financial policies, which are not otherwise covered by supplemental insurance.
  3. You are responsible for knowing your insurance policy. If you are not familiar with your plan coverage, we recommend you contact your carrier or plan provider directly. You will be responsible for any charges if any of the following apply:
    1. Your health plan requires prior authorization or referral by a primary care physician (PCP) before receiving services at ISLP, and you have not obtained such an authorization or referral.
    2. You will receive services in excess of such authorization or referral.
    3. Your health plan determines that the services you received at ISLP are not medically necessary and/or not covered by your insurance plan.
    4. Your health plan coverage has lapsed or expired at the time you receive services at ISLP.
    5. You have chosen not to use your health plan coverage.
  4. You will be required to follow all registration procedures, including updating or verifying personal information, presenting verification of current insurance, and paying any co-pays or other Client responsibility amount at each visit.
  5. Your card or other insurance verification must be on file for your insurance to be billed. If we do not have your card on file, or are unable to verify your eligibility for benefits, you will be considered a self-pay Client.
  6. As a self-pay Client, our fee is expected to be paid in full at the time of service. If the insurance card or other necessary information is furnished after the visit, we may file a claim with your insurance; and, if paid in full by your insurance, you will be reimbursed.
  7. If you are not prepared to make your co-pay or other Client responsibility amount, your visit may be rescheduled by ISLP and sessions will not be rendered until any standing payments will be resolved completely.
  8. We may verify your insurance benefits or submit your claim to your insurance carrier as a courtesy to you, however, it is you who agrees to facilitate payment of claims by contacting your insurance carrier when necessary and ISLP does not assume responsibility to contact your insurance and check your benefits, etc.
  9. You authorize ISLP and associated therapists and staff to release Client information acquired in the course of your examination and/or treatment including but not limited to any and all medical records, notes, evaluation results, reports, or other documents related to your treatment that is deemed necessary to process this claim to the necessary insurance companies, third party payors, and/or other entities as they require to participate in your care. It is important to notify us as soon as possible of any changes related to your insurance coverage. Failing to do so may result in unpaid claims, and you will be responsible for the balance of the claim.
  10. ISLP does not accept responsibility for incorrect information given by you or your insurance carrier regarding your insurance benefits or benefit plans.
  11. If your insurance carrier does not remit timely payment on your claim and claims are past 90 days due, you will be responsible for payment of the charges within the terms set forth herein.
    1. You will be billed any remaining Client responsibility, co-pay, co-insurance, etc deemed by your insurance carrier at the time of service.
    2. If any payment is made directly to you for services billed by us, you agree to promptly submit same to ISLP until your Client account is paid in full.
    3. If you make a payment that results in a surplus on your account, you authorize ISLP to apply the overpayment to any other account for which you are financially responsible, including your account, a member of your family’s or dependent’s account, or on any account for which you are a financially responsible party, and any remaining balance will be returned to the payor.

Managed Care Insurance:
All managed care co-payment amounts are due at the time of service. If your insurance plan requires a referral authorization from a primary care physician, it is your responsibility to obtain it prior to the initial session and presenting to the office at the time of service.

  1. If you request an office visit without a referral authorization, your insurance plan may deem this as “out of network” or “non-covered” treatment, and you will be responsible for all of the charges at ISLP’s private session fees. You acknowledge that it is your responsibility to be aware of what services are covered and you agree to pay for any service deemed to be non-covered or not authorized by the plan.

Referrals and Pre-authorizations:
Your insurance carrier may require a referral from your physician and/or a pre-authorization for us to provide services. It is your responsibility to obtain a referral or preauthorization if required by your insurance company. Please note that failure to obtain a referral and/or pre-authorization may result in a decreased or no payment from your insurance company.

Payment Method by Checks:
For any returned or declined checks for any reason, your account will be charged a surcharge of $25.00 or up to the applicable state maximum legal limits, whichever is lower, in addition to any costs assessed or charged by any depository institution.

  1. ISLP may require a more secure payment in the form of a money order or cashier’s check if checks are returned or declined for any reason to ensure security of payment.

Past Due Accounts:
Accounts 30 days past due will be assessed a 2% late fee finance charge monthly. If your account becomes past due, we will take steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay all of the collection costs incurred, including reasonable lawyer fees and court costs as necessary.

Monthly Statement:
If you have a balance on your account, we will send you a monthly statement. Additional statements are provided upon request. Statements beyond 3 months/90 days are not provided. Any statements requested beyond the 3 months are subject to an additional fee of $5.00 per month.

Cancellation Policy:
Consistency in treatment is important for successful progress. Scheduled appointments are held for you and are not available to others. If you are unable to keep an appointment, please call at least 24 hours in advance to avoid a no-show fee. Missed appointments will be billed the full session price and are not covered by insurance. Exceptions may be made in ISLP, Inc.’s sole discretion in the event of an emergency. All cancellations must be reported by 8:00pm the evening before, at least 12 hours ahead, otherwise the session will be charged in full for the negligent to comply by ISLP’s cancellation policy rules. Notification must be received by phone or email; a return phone call or email will be placed to confirm your cancellation. If ISLP does not receive the required notification for 3 absences, the client will be removed from the caseload and placed at the end of the waiting list. In the case of a sudden illness or family emergency when a 24-hour notice cannot be given, ISLP’s front desk and the client’s respective therapist must be notified as soon as possible to cancel the scheduled session. It is at ISLP’s discretion to decide an acceptable number of urgent cancellations before the client is fined and/or removed from caseload.

Should the client come/arrive late to the session, he/she will receive the remainder of the session’s therapy and will be charged the full session’s length. Any time changes/cancellations must comply with ISLP’s cancellation policy. If you leave a message after 8:00pm, the office will return it the next morning within operation hours. If you do not hear from the office within 24 hours of leaving a message, it is because we have not received it and ask that you kindly follow up with us again.

Confidentiality:
Our duty to maintain the confidentiality of our clients and Clients is sacred to us. Our therapy sessions and conferences are completely confidential and we will protect your privacy. We are mandated by law to report any attempted or confessed act of child abuse, elder abuse, dependent adult abuse and/or serious intent to commit homicide.

Payment by Credit Card/Credit Card on File:
ISLP may keep your credit card(s) on file, you agree to keep the credit card information current, and you authorize ISLP to securely store your credit card information, and appropriately charge it for any outstanding balances or any leftover balance in the future. You understand that you are responsible for all charges for services that you receive from ISLP.

  1. If any balance on your account is over thirty (30) days past due, your account will be in default and may be referred to a collection agency. You agree to pay all fees acquired on your account. If we have to refer your account to a collection agency, you agree to pay all of the collection costs incurred, including reasonable lawyer fees and court costs as necessary.
  2. The balance of any account not paid within ninety (60) days will begin to accrue interest at the rate of 2% per month or the maximum allowed by applicable law, whichever is lower. For small balances, between $4.01 to $25.00, we may stop sending billing statements any time after the initial statement, but you understand that the amount shall remain due and owed until paid in full.

Additional Charges:
Clients may incur and are responsible for the payment of additional charges at the discretion of ISLP including but not limited to:

  1. Charges for returned checks.
  2. Charges for a missed appointment without 24 hours advance notice (please refer to our cancellation policy below).
  3. Charges for extensive phone consultations (more than 15 minutes in length) and/or after-hours phone calls requiring treatment, or prescriptions.
  4. Charges for copying and distribution of Client medical records (above 5 pages will be subject to $0.25 charge per page).
  5. Charges for extensive forms preparation or completion that will take more than 15 minutes of write up time will be charged at our hourly fee increments.
  6. Any costs associated with collection of Client balances, all as allowed by law.
  7. Charges for phone consultations/conferences over 15 minutes in length.
  8. Charges for parent/caregiver meetings.

Minor Clients
The parent/guardian of a minor is responsible for payment of the minor’s account balance in full. A minor who is not accompanied by a parent/guardian will be denied any non-emergency treatment unless charges for the treatment have been pre-authorized. Responsibility for payment of treatment of minor children, whose parents are divorced, rests with both parents. Any court-ordered responsibility judgment must be determined between the individuals involved, without the inclusion of ISLP.

Financially Responsible Party
If this or a separate ISLP Financial Responsibility Statement is signed by another person, on your account, then that co-signature remains in effect until canceled in writing. Cancellation in writing shall become effective the date after receipt, and shall apply only to those services and charges thereafter incurred. By signing as a financially responsible party, you hereby guarantee the full and prompt payment to ISLP of all indebtedness of Client to ISLP, whether now existing or hereafter created (the “Indebtedness”); and you further agree to pay all expenses, legal or otherwise, incurred by ISLP in collecting the Indebtedness, in enforcing this guaranty, or in protecting its rights under this guaranty or under any other document evidencing or securing any of the Indebtedness. This guaranty shall be a continuing, absolute and unconditional guaranty, and shall remain in force and effect until any and all said Indebtedness shall be fully paid. There shall be no obligation on the part of ISLP at any time to first exhaust its remedies against client(s), any other party, or any other rights before enforcing the obligations of the financially responsible party.

Thank you for the opportunity to provide your health care services. Your assistance and cooperation is appreciated. By signing below, you acknowledge that you have read and understood the policies described above, and have had the opportunity to ask questions.

Client name:

Responsible party:

Relationship:

Signature:
Date:


OFFICE POLICIES

To ensure better service to our clients, we have updated our office policies. Please note the following information. Failure to comply with our office policies can result in a loss of a weekly session, notice of which will be provided in writing, at least 30 days in advance.

  1. Payment: Payment is due at the time of treatment. Payment is accepted in cash, check, or credit card. In the event that you do not remain current on your financial obligations to Innovative Speech & Language Pathology, Inc. and are delinquent on your account for more than 30 days, services will be suspended until payment is received. Services may also be terminated if it is determined that continued participation will be a detriment to the child or their family.
  2. Scheduling: all scheduling is done in advance and affects all Clients. Although we unfortunately cannot re-arrange everyone’s times for social/sport calendars or extracurricular activities, we will do our best to accommodate changes due to a serious issue, school scheduling, or mandated doctor appointments or other therapies with at least one week’s advance notice. We ask that if your schedule is flexible, please consider moving your session time to accommodate other Clients when necessary.
  3. Vacations and Holidays: This office follows a school calendar. We often offer extended hours when the schools are closed. Please notify us if you observe religious holidays so that we can make arrangements to accommodate your needs. If you will be on vacation, please notify the office at least 2 weeks in advance. If you plan a vacation for more than 2 consecutive weeks, you will be asked to either pay a fee to hold your weekly slot, or to make up the missed sessions. We will always notify you in advance of any vacation time we may take, and offer make-up sessions when available.
  4. Cancellations: Please refer to and comply with our cancellation policy above.
  5. Communication: Please note that if it is a weekend, holiday, or we are on vacation, we may not be able to answer your questions immediately, however, your concerns will be addressed as soon as possible. All calls/texts/e-mails are generally answered within 24 hours; should you not hear back within this time frame, please contact us again to ensure your message was received. Please do not text or call past 5:00PM or on the weekends with therapy-related questions (unless urgent), as we all need time off with our families. E-mail is the preferred method of professional communication, thank you.
  6. Phone Calls: We do not mind when parents have questions about their child’s progress or therapy care, however, discussions longer than 10 minutes will need to be scheduled, like any medical office. If you have questions that require a lengthy discussion, you will need to set up an appointment time or a 30 minute phone consult at the fee of $45. Although we will respond to e-mails, for questions which require a lengthy/detailed response, we will need to set up an appointment or phone consult. It is part of our duty to collaborate with all professionals working with our clients, and as with any school or medical office, you need to schedule time for conference calls or meetings honoring the hourly rate of the office.
  7. Reports: All clients are charged an annual yearly fee, which includes a report with goals and objectives. This report will then be reviewed 4x a year. This serves both schools and insurance companies. Re-evaluations per parental/third party request are at a charge of $475.00, which includes a report with goals and objectives. You will receive a receipt for an evaluation to submit to your insurance company. (The fees are subject to change depending on each client’s needs). The re-evaluation fees are different than the initial assessment fees.
  8. Parent/Caregiver Meetings: Parent/caregiver meetings will occur twice a year at no charge. Any additional requests for meetings with parents/caregivers, other professionals, teachers, etc. will be charged at the private hourly fee. This fee is subject to change.
  9. Waiting Room/Bathroom: The waiting room is a place for families to relax and socialize before, during and sometimes after an appointment. Please refrain from excessive conversations on your cell phone and/or loud play with your children in our waiting area. The waiting room is a “shared” waiting room amongst all therapists on the floor and noise does carry through. Therefore, please be mindful of the noise level to prevent disruptions of therapy sessions. Please keep your child in the waiting room and do not allow your child in the hallway, as this disrupts other tenants in our building. Bathrooms in the outer hallway are for all Clients in the waiting area; please ask for the key to the bathroom from the front desk. If you arrive early or late for sessions, please make sure to notify us. Please DO NOT enter the therapy facility without being accompanied by a therapist. This is for the privacy of other Clients, as well as our staff. If you have a nanny or family member bringing your children, please review our waiting room policies with them.
  10. Lateness: If clients are late, they will only receive therapy until the end of the time slot they were assigned. For example, if a client arrives at 3:45 p.m. for a 3:30 p.m. session, we will still end at 4:30 p.m. Should we be late to a session, we will deliver the full therapy time. For example, if we arrive at 3:45 p.m. for a 3:30 p.m. session, we will end at 4:45 p.m. Please be on time for your session to help ensure maximum progress gains. Also, to keep the office running smoothly, please have your form of payment (cash/check/credit card) ready before each session, and be prepared to exit the therapy room on time. Ask any questions you may have at the start of the child’s session. Parental conferences must occur during the first or last 5 minutes of a therapy session. If you require a longer conference please refer to #6 above.
  11. Observation: Due to the nature of oral motor, feeding and myofunctional therapy, parents are asked to stay in the therapy room to observe the session for the purpose of parental training. It is very important that parents are “passive observers” and do not interfere with clinical rapport and the flow of the therapy session. For example, if a child starts to cry, observe the way in which the therapist handles the behavior rather than try to comfort or discipline your child yourself. In most cases, clients do much better when alone with their therapist since they do not have their “security blanket” or are not concerned by “pleasing their caregiver(s).” Therefore, on occasions where observation seems to have a negative impact on the session, you may be asked to wait outside. Please do not take this personally, as some children need to establish a clinical relationship with the therapist and are too distracted by their parents. In time, we will re-visit observation.
  12. Discontinuation of Services: If you plan on discontinuing services for any reason, you must give this office at least 1 week notice or you will be billed for the missed sessions. A discharge report will be prepared free of charge if you have been up to date with payments and give this office sufficient notice.
  13. Health Policy: Please be mindful that due the nature of our therapy, we work very closely with your child’s oral cavity. We are therefore are constantly in contact with your child’s saliva and therefore, if your child is ill, we are susceptible to getting sick as well. Please comply with our health policy to help maintain a healthy environment for the clinicians as well as other clients. In the event your child has the following symptoms, please refrain from bringing your child/children to therapy:
    1. If your child is vomiting and/or has diarrhea (he/she should not return to therapy until 24 hours have passed since the last episode of the same);
    2. If he/she is too ill or uncomfortable to function in therapy setting;
    3. If he/she has a continual runny nose, thick or discolored nasal discharge, and is too young to clean his/her nasal discharge;
    4. If he/she has excessive sneezing or coughing and mucus-producing cough;
    5. If he/she has an elevated temperature (a child must be temperature free for 24 hours before returning to therapy).
  14. Failure to comply with the health policy will result in the termination of the session, and the session will be charged at full therapy fee without a make-up session.

Signed:
Date:

Consent Form

Notice of Privacy Policies

Our legal duties: State and federal laws require that we keep your medical records private, as well as provide you with this notice of your rights and our duties. ISLP, Inc. is required to abide by these policies until replaced or revised. We have the right to revise our privacy policies with regard to medical records, including records kept before policy changes were made. You will be notified of any changes to this notice. The information disclosed to us in an evaluation, intake and/or counseling sessions are covered by the law as private information.

Use of information: Information about you may be used by the personnel associated with ISLP, Inc. for diagnosis, treatment planning, treatment, and continuity of care. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian or personal representative. ISLP, Inc. will not release any information about a client without a signed release of information form except:

  • When a client discloses intentions or a plan to harm him/herself or other person(s)
  • When a client discloses or implies a plan for suicide
  • When a client states or suggests that he/she has or is abusing a child or vulnerable adult
  • When a client is the victim of abuse, neglect, violence, or a crime, and his/her safety appears to be at risk
  • When there is a report of prenatal exposure to controlled substances that are potentially harmful
  • Health records may be released for the public interest and safety for public health activities, judicial and administrative proceedings, law enforcement purposes, serious threats to public safety, essential government functions, military, and when complying with worker’s compensation laws.
  • In the event of a client’s death, the spouse or parents of a deceased client have a right to access their child or spouse’s records.
  • Professional misconduct by a health care professional must be reported by other health care professionals. In cases in which a professional or legal disciplinary meeting is being held regarding the health care professional’s actions, related records may be released in order to substantiate disciplinary concerns.
  • When a court order has been placed, in which case only the minimally acceptable amount of information will be revealed. Additionally, if a client files a complaint or lawsuit against anyone affiliated with Innovative Speech & Language Pathology, relevant information regarding the client may be disclosed for the purpose of formulating an appropriate defense.
  • Parent(s)/legal guardian(s) of non-emancipated minor clients have the right to access the client’s records unless it is determined that access would have a detrimental effect on the therapeutic relationship, or on the client’s physical safety or psychological well-being.
  • When there has been a failure to comply with financial policies, collection agencies may be utilized in collecting unpaid debts. The specific content of the services (e.g., diagnosis, treatment plan, progress notes, testing) is not disclosed.
  • Insurance companies, managed care, and other third-party payers are given information that they request regarding services to the client.
  • Information about clients may be disclosed in consultation with other professionals in order to provide the best possible treatment.
  • Communication with the client outside the clinic setting will only occur as authorized by the client.
Signed:
Date:

Client’s Rights Notice

  1. You have the right to your medical files. If your request is denied, you will receive a written explanation of the denial. Records for non-emancipated minors must be requested by their custodial parents or legal guardians and the charge for this service is $0.25 per page, plus postage.
  2. You have the right to cancel your authorization of release of information by providing ISLP, Inc. with written notice.
  3. You have the right to restrict what information might be disclosed to others.
  4. You have the right to request that information about you be communicated by other means or to another location.
  5. You have the right to disagree with the information in your medical records. You may request that ISLP, Inc. change this information. In the event ISLP, Inc. refuses to make the requested change, you have the right to make a statement of disagreement, which will be placed in your file.
  6. You have the right to know what information in your records has been provided to whom.
  7. You have the right to request a copy of this notice.
  8. You have the right to refuse or terminate services at any time for any reason, with 4 weeks’ notice to ISLP, Inc.
  9. You have the right to submit complaints or suggestions at any time, which will be carefully considered and investigated, as appropriate, for the betterment of our services.
  10. You have the right to information regarding the cost of services. ISLP, Inc. will always inform you of charges before we provide a service.
  11. You have the right to privacy; please refer to our privacy policies.
  12. You have the right to know under what conditions we will terminate our services; please refer to office policies.
  13. You have the right to be informed of any changes in our policies and will be notified in the event that we change a policy that is relevant to the services we provide.
Signed:
Date: