By agreeing to these terms, the parent authorizes Austin Pediatric Speech and Language, LLC to render appropriate assessment, screening and therapy services to my child. I understand that care will be provided by an appropriately trained healthcare professional. I recognize and agree that I have the right to refuse treatment or terminate services at any time. In addition, Austin Pediatric Speech and Language, LLC may terminate services by notifying the parent of termination. I consent and agree that Austin Pediatric Speech and Language, LLC and its staff may contact me, leave voice messages, send me text messages and/or send me emails to the phone number(s) and email address(es) provided. I understand that these messages can include protected health information, such as patient name, appointment information, billing information, information that identifies the practice as a speech therapy practice, and my pertinent clinical information. I understand that appointment reminders through text messages and treatment information through emails are not secure forms of communication and the by consenting to these communication types, I am waiving my rights to secure electronic communication. If you do not wish to communicate with your clinician through text messages, let them know.

Financial Responsibility and Payment Terms

We are in the business of caring for kids. That is our passion, but it is a business. So, we hope that you will help us by following these payment terms for speech therapy. The parent understands that they are responsible for payment for services provided by their clinician. If a balance is incurred, for whatever reason an invoice will be sent to you via email. This invoice needs to be paid upon receipt. All therapy will be paused and all evaluations and progress reports will not be released until outstanding balances over 30 days old are paid in full.

Cancellation Policy

It is very important for the child to attend their regularly scheduled appointments. These scheduled appointments are part of a recommended treatment plan aimed at improving health, function, and overall quality of life of the child. Without regular and consistent attendance, the benefits of therapy will be limited or the overall therapy will take longer. The parent understands that they must notify Austin Pediatric Speech and Language, LLC of all appointment cancelations 24 hours in advance. The parent understands that a $50 fee for missed appointments without 24h notice could apply because Austin Pediatric Speech and Language, LLC will need to compensate SLPs for their time. This fee will be waived, if the appointment is rescheduled within 5 business days of the original appointment assuming that there are appointments available, which may be the case. If the child is late for an appointment, the therapy session will still end at the originally scheduled time unless accommodations can be made. We, of course, will excuse missed appointments due to severe weather conditions. We understand that families are busy and schedules are often difficult to manage, however, If more than 3 cancellations/no-shows occur within a patient’s recommended plan of care timeframe, Austin Pediatric Speech and Language, LLC holds the right to discontinue therapy services.

Consent to Release/Obtain Protected Health Information/Waiver HIPAA Liability

This seeks authorization for the use and/or disclosure of the specific personally identifiable health information set forth made pursuant to the requirements of 45 CFR §164.508, which states the federal privacy regulations of the Health Insurance Privacy and Accountability Act of 1996 and authorizes Austin Pediatric Speech and Language, LLC to obtain the personally identifiable health information specifically referenced in this authorization. The parent gives consent to therapists and administrators employed by Austin Pediatric Speech and Language, LLC to use and disclose personally identifiable health information for treatment of the patient in accordance of the Notice of Privacy Practices. The parents also consents to the use and disclosure of the patient’s protected health information to the primary care physician/pediatrician and any of the healthcare professionals and/or educators if necessary.

Waiver of HIPAA Liability

Due to federal guidelines protecting all private patient health information, Austin Pediatric Speech and Language, LLC has a policy in place that prohibits discussion of all information regarding your child’s assessment, treatment and care, in public areas such as the street, the school halls, etc. All discussions regarding the child/children should take place in a private room away from the general public. By agreeing to this waiver of HIPAA liability, you as the parents or guardians, are 1) agreeing not to initiate a conversation regarding patient health information in a public setting, like our waiting room and 2) releasing Austin Pediatric Speech and Language, LLC from any harm or fault caused by discussions of the private health information in open access areas in our facility such as the waiting room or administration office with you as the parent or a preferred guardian you send to accompany your child to their therapy sessions. We encourage ongoing discussion between the therapist and family, so we’ll find you a suitable place to talk.

Communication Preference

Protecting the privacy of your child and your family is extremely important to us, and HIPAA mandates it. While we prefer to give you updates in person after therapy, there will be times when you will want us to send you written information. The HIPAA privacy rule allows us to communicate with you electronically provided that we apply reasonable safeguards when doing so, including encryption, limiting personally identifiable information like full names, etc. The privacy rule does not prohibit the use of unencrypted email and text for treatment-related communications. Please understand that if you consent to receive unencrypted emails and appointment reminder text messages, then there is a risk that a third party may be able to obtain that information during transmission or while stored on a computer or phone. For written initial or progress reports, updates etc, we offer paper versions.