Cornerstone Speech Therapy

“Your Home for Family-Centered Services”

Welcome to Cornerstone Speech Therapy!

At Cornerstone Speech Therapy, we want to give your child a solid foundation, or cornerstone, for development. This starts with involving you in your child’s learning. We are a private practice of dedicated professionals who love working with children and families in the home or our “home-like” office setting. We believe that children learn best through opportunities within their daily routines and activities. From experience, we have found that significant progress can be made when you are an active participant in the therapy process. Our effective interventions are focused on the priorities your family has for your child and we include you every step of the way. You are the expert on your child and we are excited to partner with you.

If at any time, you would like something to change or if we are not providing the services you expect, please let us know. This is a partnership and we want you to feel comfortable communicating your priorities with us. Also, we want you to stay informed about the latest research and resources in your community. Please stay connected with us at cornerstonespeechtherapy.com and follow us on Facebook (search Cornerstone Speech Therapy LLC) and Twitter (search CornerstoneST).

Thank you for choosing Cornerstone Speech Therapy. We look forward to serving your child and your family.

Sincerely,

Janelle Pickens, MS, CCC-SLP

Speech-Language Pathologist/Owner

Why Family-Centered Services?

Cornerstone Speech Therapy prides itself on an approach that is different from

many other providers. Why have we chosen this approach?

Not only does it just make sense to provide services that include and

inform families, but our approach is also backed by research.

We believe, and research shows, that the family unit is the most important and influential part of a child’s development. Children learn the most from the people who are closest to them. Your family has cared for your child since the very beginning and, through this time together, you have become a true expert on your child. Your family knows and understands what makes your child happy, sad, uncomfortable, excited, scared, and sometimes even grumpy. You know your child's strengths and interests and you understand their challenges. Because of the respect we have for your family's knowledge and experience, Cornerstone partners with you to understand these special qualities and develop strategies that address your family's priorities for your child.

Family-centered services also empower your family to incorporate intervention strategies into your child’s daily routines. Intervention is not something that only happens once a week during a speech therapy session, but should occur multiple times per day through activities in which your child naturally participates. Your family is already doing things that can be powerful learning opportunities. These activities can be anything from folding laundry to wrestling with daddy and are unique to your family. Because of our approach, your family will not have a designated time in your day to “work on speech” because it will naturally be embedded in each and every activity you experience with your child.

A visit with Cornerstone may also look different from a traditional therapy session. Because of our emphasis on family involvement, your family is asked to participate and learn how to best help your child. Our visits take place either in your home or in our "home-like" office location. We use a coaching approach as we work with your family. We ask questions, model strategies and allow your family the opportunity to try some things while we are there. We want you to have the confidence and competence to support your child’s development on your own.

At Cornerstone Speech Therapy, your family is at the very heart of what we do. While we may be experts on speech and language development, we know that you are the expert on your child. Cornerstone truly is “your home for family-centered services".

Family and Child Information

Child’s Name: ______Date of Birth: ______

Address: ______

Mother’s Name: ______Occupation (optional):______

Home Phone: ______Cell Phone: ______Email: ______

Father’s Name: ______Occupation (optional): ______

Home Phone: ______Cell Phone: ______Email: ______

Would you like to sign up for our quarterly newsletter? Yes ______No ______

Pediatrician: ______Phone: ______

Names/Ages of Siblings: ______

How did you hear about us? ______

Please tell us why you chose Cornerstone Speech Therapy: ______

______

What are your family’s priorities for your child? ______

______

Please describe your child’s current communication abilities: ______

______

Have you worked with any other speech-language pathologists or had a speech-language evaluation completed recently? What were the recommendations? We would appreciate any copies of reports you can give us. ______

______

What other professionals have worked with or are working with your child? (service coordinators, early intervention specialists, physicians, psychologists, audiologists, occupational therapists, physical therapists, special education teachers, etc.) ______

______

Does your child have a significant medical history or medical condition you would like to share with us? Any known vision or hearing difficulties? ______

______

Describe your child’s development. Did he/she meet developmental milestones on time?_____

______

If your child has an existing IFSP or IEP, what goals from these plans would you like us to address? We would appreciate a copy of this plan for our records. ______

______

Tell us about your child. What are his or her special interests? Describe his or her personality.

______

Please describe the strategies you have tried with your child. Were they successful? Why or why not? ______

______

What do you expect from our visits? How do you want them to look?

______

Please provide any additional information that we may need to best serve your child and your family: ______

______

Besides just speech and language services, what do you need as a family to better support your child overall? ______

______

Consent for Treatment

I hereby give my permission to the staff of Cornerstone Speech Therapy to carry-out all necessary diagnostic, assessment, and treatment services that will address the needs of the above named client.

______

Parent or Guardian Signature Date

Family and Provider Agreement

At Cornerstone Speech Therapy, our goal is to partner with you to help your child succeed. We value your ideas and contributions and believe that your child can make better progress when you are actively involved.

So that we can provide meaningful services that meet the unique needs of your child, please respect the following guidelines during our visits:

Be present and participate with us and your child.
Communicate your families’ priorities for your child.
Share with us your child’s strengths and interests.
Tell us about what you have practiced during the week.
Develop a plan with us at the end of each visit.
Keep distractions to a minimum (ex. television, phone use, etc.)

We agree to do the following:

Capitalize on your child’s interests and family activities.
Develop strategies that address your priorities.
Provide information on speech and language development.
Demonstrate and practice evidence-based techniques.
As much as possible, use toys and other items that you already have in the home to promote immediate carry-over.
Provide written summaries at the end of each visit and periodic progress reports.
Communicate with other professionals and caregivers in your child’s life when appropriate.

Thank you for the opportunity to serve your child and your family. Please speak with your provider with any questions or concerns or contact our Family Service Coordinator, Jennifer Pierson, at (614) 973-9755. Also, feel free to complete our on-line survey at any time.

______

Parent SignatureDate

Agreement To Pay

Cornerstone accepts a variety of funding sources, including some insurance plans. Some families choose to pay privately. Cornerstone will make every effort to obtain payment on your behalf. Please read the information below so you better understand the payment terms required.

Insurance Company / Funding Source: ______

____ We are in-network with your insurance company.

You are responsible for any co pays, deductibles or non-covered service on your plan.
You are responsible for payment if your insurance company does not respond with-in 90 days of claim submission.
You are responsible for payment in full if your claim is denied as a non-covered service.
You are responsible for obtaining physician prescriptions and referrals required by your insurance company.

____ We are out-of-network with your insurance company.

Cornerstone Speech Therapy will bill your insurance on your behalf.

You are responsible for payment in full 30 days from invoice. Any reimbursement will be sent directly to you from your insurance company.
Your insurance company may not correspond with us. You must let Cornerstone Staff know if your insurance company needs additional information.
Cornerstone can automatically debit your credit or debit card for easier payment options.

____ Private Pay Client.

Payment is due 30 days from Invoice date.
Cornerstone can automatically debit your credit or debit card for easier payment options.

_____ Alternative Funding Source.

You are responsible for signing any required documents in a timely manner.
You must notify Cornerstone immediately of any change in your funding status. You are ultimately responsible to pay for any service rendered without proper authorization for the funding source.

Please contact Cornerstone Speech Therapy with any questions regarding your funding. We are happy to assist you to determine the best payment option based on your family’s needs and eligibility.

______

Parent or Guardian Signature Date

Assignment of Benefits

I authorize my third-party payer (insurance or other payers) to assign benefits to Cornerstone Speech Therapy. I authorize Cornerstone Speech Therapy to file claims on my behalf and accept assignment of benefits.

Check Return Policy

There will be a $25.00 fee for each returned check.

Past Due Accounts

Clients with an outstanding balance may have services placed on hold until arrangements can be made to meet the financial obligations. After 60 days, outstanding balances may be charged a 1.5% interest fee and be turned over to a collections agency.

Ohio Medicaid Waiver Agreement

I understand Cornerstone Speech Therapy is not a provider for the Ohio Medicaid Program. I understand that by choosing Cornerstone Speech Therapy, I am waiving my ability to utilize Ohio Medicaid benefits for any services rendered at Cornerstone Speech Therapy.

______

Parent / Legal Guardian Signature Date

Auto Debit Agreement for Cornerstone Speech Therapy

I ______hereby authorize Cornerstone Speech Therapy to debit my card for on-going speech therapy sessions in the amount of $______.

Visa / MC / Discover / Amex – please circle one

Card Number ______

Expiration Date ______/ ______

CV code ______- back of your card

Client Name: ______DOB: ______

______

Cardholder Signature Date

Attendance Policy

Regular attendance is important for your child and family’s success and we will make every effort to schedule appointments that meet your needs. In order to provide the best services possible for all of the families in our practice, we ask that you follow the attendance policy outlined below:

Cancellations: Please notify us at least 24 hours in advance to cancel your appointment.
Missed appointments: If there is a pattern of frequent cancellations or no shows, our services may be discontinued or put on hold at the discretion of the management.
Late for Appointments: If you are more than 15 minutes late for your appointment, we reserve the right to cancel the appointment and consider it a missed appointment.
Clinician Cancellations: If your therapist is not able to attend your appointment, you will be contacted as soon as possible. Please be sure that we know the best way to reach you. Every effort will be made to reschedule your appointment in a timely manner.

To cancel an appointment, please contact your therapist ______:

Phone ______
E-mail ______

□ I have read and understand the policy listed above.

______

Patient Name

______

Parent/Guardian Signature Date

Notice of Privacy Practices

As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU and YOUR CHILD (as a patient of this practice) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

OUR COMMITMENT TO YOUR PRIVACY

Cornerstone Speech Therapy is dedicated to maintaining the privacy of your individually identifiable health information (IIHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your IIHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:

How we may use and disclose your IIHI
Your privacy rights in regard to your IIHI
Our obligations concerning the use and disclosure of your IIHI

The terms of this notice apply to all records containing your IIHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our office in a visible location at all times, and you may request a copy of our most current Notice at any time.

IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

Practice Administrator, PO Box 16092, Columbus, OH 43016

Cornerstone Speech Therapy may use and disclose your IIHI in the following ways:

1. Treatment. Our practice may use your IIHI to treat you. For example, we may ask you to have laboratory tests (such as audiology or developmental evaluations), and we may use the results to help us reach a diagnosis. Many of the people who work for our practice – including, but not limited to, our speech pathologists – may use or disclose your IIHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your IIHI to others who may assist in your care, such as your spouse, children or parents.

2. Payment. Our practice may use and disclose your IIHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your IIHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your IIHI to bill you directly for services and items.

3. Health Care Operations. Our practice may use and disclose your IIHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your IIHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice.

4. Appointment Reminders. Our practice may use and disclose your IIHI to contact you and remind you of an appointment.

5. Treatment Options. Our practice may use and disclose your IIHI to inform you of potential treatment options or alternatives.

6. Release of Information to Family/Friends. Our practice may release your IIHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child to the office for a treatment session. In this example, the babysitter may have access to this child’s medical information.

7. Disclosures Required By Law. Our practice will use and disclose your IIHI when we are required to do so by federal, state or local law.

USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL CIRCUMSTANCES

The following categories describe unique scenarios in which we may use or disclose your identifiable health information:

1. Public Health Risks. Our practice may disclose your IIHI to public health authorities that are authorized by law to collect information for the purpose of:

maintaining vital records, such as births and deaths
reporting child abuse or neglect

preventing or controlling disease, injury or disability

notifying a person regarding potential exposure to a communicable disease
notifying a person regarding a potential risk for spreading or contracting a disease or condition
reporting reactions to drugs or problems with products or devices
notifying individuals if a product or device they may be using has been recalled
notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information

notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

2. Health Oversight Activities. Our practice may disclose your IIHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.