Therapy Informed Consent and Financial Agreement
I hereby authorize Origin Speech Therapy to provide skilled services to address identified needs in speech, language, feeding, swallowing, and/or orofacial myology per our mutually agreed-upon plan of care.
I further agree to each of the following:
- Agreement Terms: The agreement will terminate when all of the following are true: the client is discharged from services, the account is paid in full, and the case is closed in our system.
- Payment Information: I agree to keep an active card on file and to notify Origin Speech Therapy of any change of address, account number, or financial responsibility.
- Payment and Fee Schedule: I agree that I will be charged for each session at the time of the service. The fee schedule for self-pay clients is $199 per initial evaluation and $95 per 30-minute treatment session. Rates for insurance-pay clients differ depending on your insurance.
- Financial Responsibility: I agree to pay all co-pays, deductibles, coinsurance, and any other charges not covered by their insurance. If the insurance company denies payment or only partially covers the service, I agree to be responsible for the remaining balance. Charges are due and payable upon receipt of the bill unless a mutually agreed upon payment plan has been established with Origin Speech Therapy.
- Treatment Sessions: I understand that treatment sessions and frequency are individually based. Each 30-minute treatment window will consist of 25-27 minutes dedicated to direct care activities and/or consultation, with 3-5 minutes for session preparation and documentation. For longer sessions, the time will be adjusted proportionally.
- Session Timing: I understand that my scheduled treatment time is the only time dedicated to my treatment on my therapist’s schedule. If I arrive late to my session, I will not receive the full treatment time, and my session will not extend into another scheduled appointment. I understand that I will be charged the full amount for this session.
- Cancellation and No-Show Policy: I understand that I will be billed a $50 fee for any no-show or late cancellation. A "No Show" is defined as a scheduled visit that I do not attend and do not notify the therapist in advance. A "Late Cancel" is any visit canceled within 24 hours of the scheduled appointment. I understand that I can request to reschedule visits rather than cancel them. No shows will automatically incur the $50 fee, which will be charged to my saved payment method on file.
- Account Balance: I understand that I will not be permitted to schedule any additional treatment visits if my account has an unpaid balance of any amount.
- Teletherapy Services [if applicable]: Where appropriate, the services you receive may be provided by telephone or videoconferencing. I understand that I am responsible for the costs associated with setting up the technology needed to access teletherapy services. Origin Speech Therapy will cover the cost associated with the platform used to conduct teletherapy services.
- Teletherapy Setup Requirements [if applicable]: To access teletherapy sessions, I agree to provide a quiet, private space; the appropriate device (e.g., smartphone, laptop, iPad, computer) with a camera, microphone, and speakers; and a reliable internet connection. I understand that the privacy of any form of communication via the internet is potentially vulnerable and limited by the security of the technology used. Origin Speech Therapy uses Zoom, which is compliant with international standards for online security and encryption.