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 firstname.lastname@example.org or call us at 310-659-9511.
We look forward to meeting you and your child soon.
Odelia Mirzadeh, M.S., CCC-SLP 8665 Wilshire Blvd. Ste.#412, Beverly Hills, CA 90211 E: Odelia@innovativeslp.com www.innovativeslp.com
Client date of birth:
Place of employment:
Address and phone number of school:
Person responsible for payment:
Who can we thank for their kind referral:
Date of birth:
Insured's address (if different from client):
Insured's Social Security Number:
Employer name and 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).
Parent/guardian name if minor:
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.
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.
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.
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.
Additional Charges: Clients may incur and are responsible for the payment of additional charges at the discretion of ISLP including but not limited to:
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.
I elect to have ISLP, Inc. bill me at the time of service.I elect to pay for 10 sessions in advance and receive a discount (please discuss with front office staff or ISLP manager).
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.
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.
I hereby acknowledge and agree that I have received a copy of Innovative Speech & Language Pathology’s office policies, including payment policies, and have read, understand and consent to be bound by its contents.
I hereby acknowledge and agree that I have received a copy of the Client Rights Notice, and have read and understand and consent to be bound by its contents.
I hereby acknowledge and agree that I have been provided a copy of ISLP, Inc.’s Notice of Privacy Policies detailing how my and/or my child’s medical records may be used and disclosed under federal and state law. I understand that as a part of ISLP, Inc.’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity and I consent to such disclosure for these permitted uses, including disclosures via fax and e-mail. I fully understand and accept the terms of this consent form and understand that I may revoke this consent in writing, except to the extent that the company has already taken action in reliance thereon. I understand that by refusing to sign this consent or revoking this consent, ISLP, Inc. may refuse to treat me and/or my child. I further understand that ISLP, Inc. reserves the right to change its privacy policies at any time and will provide me with a copy of any revised notice.
I authorize the use of a photocopy of this consent form as if it were an original executed consent.
Release, Waiver, Indemnity and Hold Harmless. I, for myself, my minor child and for the child’s other parent and/or guardian, hereby release, waive, discharge, and covenant not to sue ISLP, any non-profit partner of ISLP, and their members, officers, directors, trustees, employees, agents, volunteers, heirs and assigns of and from all liability, loss, claims, demands, and possible causes of action arising from any loss, damage or injury to me or to my child’s person or to our property in any way resulting from or connected with my or my child’s participation in any activities conducted at ISLP including, without limitation, the failure of anyone to enforce rules and regulations, failure to make inspections, or the negligence of other persons.
I hereby release, waive, and discharge ISLP, any non-profit partner of ISLP, and their members, officers, directors, trustees, employees, agents, volunteers, heirs and assigns from any and all liability, claims, demands, actions and causes of action whatsoever whether or not such liability is based on negligence, arising out of or related to any loss, damage, or injury that may be sustained by my child or me while participating in the Activity. I further hereby agree to indemnify and hold harmless the Releasees from any loss, liability, damage or costs that may incur due to my participation in said activity. It is my express intent that this agreement shall bind the members of my family and spouse (if any), if I am alive and expressly represent if the individual participating in the Activity is under eighteen (18) years of age that I have legal authority to enter into this agreement his or her parent or legal guardian. I agree that this document shall be construed in accordance with the laws of the State of California.
Medical Authorization, Health Attestation and Financial Responsibility. I understand that ISLP will not be responsible for any medical costs associated with an injury that I/my child may sustain. I hereby authorize ISLP employees conducting and other representatives assisting with the tryouts to obtain medical care, treatment and transportation for me/my child for any injury or illness suffered during the activity, including emergency transportation and care. I acknowledge and agree that I am financially responsible for all costs associated with any medical transportation or care obtained by ISLP officials or representatives under this authorization. I understand and agree on behalf of myself, my dependents, heirs, administrators, legal representatives, and assigns, to release and hold harmless ISLP and any and all associates, employees, agents and representatives thereof, from any and all liability for illness, injuries, or death, and for any losses or damages relating thereto, however occurring, in relation to my consultation with and/or treatment by ISLP. Without limitation, I understand and agree that neither ISLP, nor any associates, employees, agents or representatives thereof, is liable for any direct, indirect, consequential, or incidental damage, injury, death, loss, delay, or inconvenience of any kind which may be occasioned by reason of any act or omission, including, without limitation, any willful or negligent act or failure to act, or breach of contract. In addition to the above authorizations, I hereby grant my permission to qualified health care professionals and staff to administer immediate treatment to my child or me should such care be deemed professionally necessary. I understand that ISLP officials are not responsible for administering any prescription or nonprescription medication.
I certify that with respect to any medical conditions or concerns I may have, I have been advised to consult with my personal care physician, and understand that ISLP and its therapists and/or employees, are not a primary care physician, and I do not view her as my physician. ISLP specializes in a natural approach to healing including, but not limited to, essential oils and homeopathy. I understand that ISLP, its staff, therapists and/or employees do not handle medical conditions or emergencies and do not maintain hospital privileges. I also agree that if I am taking essential oils or homeopathy while under treatment with ISLP I will not change them without consulting ISLP. I also understand that email is not confidential, secure or 100 percent reliable. If I have an urgent question I will call the office. If I feel it is an emergency I understand that I need to call 911 or go to the nearest emergency room. I understand and agree that ISLP, its staff, therapists, employees, volunteers, or its affiliates make any claims whatsoever, expressed or implied, regarding effects or outcomes of the analyses or therapies provided, and shall not be liable for same. I certify that I seek the advice and treatment of ISLP solely in my personal capacity, and do not represent any governmental agency, law firm, attorney, or investigator. I am not involved in a lawsuit nor am I gathering information for a potential lawsuit.
IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Informed Consent, Release of Liability and Medical Authorization and that I understand it and sign it voluntarily as my own free act and deed. I further acknowledge that: no oral representations, statements or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this document for full, adequate, and complete consideration fully intending to be bound by same.
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: