Acknowledgement of receipt and understanding of Gold Speech Policies
The first session(s) is often spent with both the parent and the child, so the therapist may learn as much about him/her as possible. We can work together on establishing appropriate communication goals that will best serve home life and school life, or work life in the case of adults. Clients are asked to share relevant reports ahead of time for the therapist to review. The first session fee is elevated to include the intake fee, consisting of preparation for the case and review of reports. If we conduct our own evaluation prior to beginning therapy, the intake fee is waived. If the sessions are to take place at a daycare or school site, parents are responsible for arranging permission with the site administration and staff. The client will be billed for any time/money spent on obtaining clearance to work with your child at daycare or school.
Clients must notify their individual therapist by text message as soon as they know they must cancel a session. Any cancellations that do not meet the criteria below will be charged for part or all of the session, according to our policy below. Note that these charges will not be reimbursable by insurance.
—– 7:00 PM to 7:00 AM Rule —–
Cancellation by text message to your therapist prior to 7:00 AM the day-of a session will be accepted without penalty.
Cancellation by email to your therapist prior to 7:00 PM the day before will be accepted without penalty.
Cancellation by text after 7:00 AM the day-of will be charged one half the session fee.
No-shows will be charged the full session fee (i.e. if the therapist arrives as scheduled and the client is not there.)
We do our best in accommodating your family’s needs for changes in the therapy schedule. If your therapist has to cancel a session, she will try to offer a makeup. Planned time off will be discussed in advance. If extenuating circumstances have caused you to miss a planned session, you may email Dawn to discuss the situation. Clients who cancel more than 20% of the time are subject to termination of services.
Dawn is a mother of three and knows how difficult it is to predict whether a child is going to be sick the next day! She has designed her practice policies to be flexible and accommodating to family needs. She elected the 7:00 AM cut-off based on her estimation that most clients are awake by that time and know if they need to cancel their session that day. Dawn also designed the policy to respect the time of her Associates, who pack session materials and plan for their whole day before they leave for work in the morning.
Gold Speech requires payment at the time of session or in advance. Payment methods are credit card or check. Your individual therapist handles the clinical aspects of treatment and should not be asked to manage payments. Dawn will send you more information once you are ready to be scheduled.
If you requested a statement to submit to your insurance for reimbursement, Gold Speech will generate a customized monthly superbill, which serves as a receipt/paid invoice. You will receive this within one week of the following month via email. The superbill contains the necessary billing and diagnostic codes required by insurance companies to reimburse out-of-network providers. Gold Speech does not work with insurance companies directly, but we are happy to return a quick phone call or send any piece of information they need. If your insurance requires reports such as treatment plans or progress summaries, we charge a fee based on time for write-up. Refer to the Pricing and Payment page for more information.
Clients may arrange for group sessions to take place. Small groups have the advantages of peer modeling, fun social dynamics, economic savings, and time savings in the case of paired siblings. If a group member cancels on a specific day, causing only one member of the group to remain, the family can elect either a shorter treatment session for that day or the full fee for an individual session of the same length.
Termination of Services
Gold Speech requires a written 2-week notification of termination of speech therapy sessions. The client will be billed for the remaining scheduled sessions within that two week period, regardless of whether the client participates.
We reserve the right to withdraw services from any client who:
– Repeatedly cancels sessions (more than 20% of the time)
– Repeatedly fails to make timely payment
– Treats their therapist or any members of Gold Speech disrespectfully
Our style at Gold Speech is very open and conducive to meeting the needs of the client and family. Dawn and her team members and have done classroom observations, consults with psychologists and teachers, and co-treatments with behaviorists and occupational therapists. Clients can arrange to use the speech session as a consultation with their therapist to discuss specific questions they have, or to collaborate with another provider. Any visit, consultation or telephone call will be billed at an hourly rate, prorated to the duration of the meeting.
Thank you very much for the opportunity to work together!
Notice of Privacy Policies and Practices
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law (Public Law 104-191), passed by Congress in 1996 that, among other things, protects an individual’s right to keep and/or transfer his or her health insurance when moving from one job to another and sets out certain administrative procedures, like ensuring the privacy of an individual’s protected health information and providing security for electronic data sharing of protected health information.
The purpose of this notice is to describe:
- How health information about your child may be used and disclosed
- How you can get access to your child’s health information
- How the privacy of your child’s health information is important to us
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Gold Speech is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide notice of our legal duties and privacy practices with respect to your protected health information.
Uses and Disclosure of your Health Care Information
Disclosure: You have the right to a written accounting of the instances in which our agency or our business associates disclosed your child’s health information for purposes other than treatment, payment or our agency’s operations for records. The list will not include disclosures made for national security purposes or to law enforcement personnel.
Treatment: With your permission, we may use or disclose your child’s health information to other healthcare providers involved in your child’s care (i.e. pediatrician, speech therapist, psychologist). All members of Gold Speech (Associates and office assistants alike) are required to keep any information about our clients confidential.
Payment: We may use or disclose your child’s health information to assist you to obtain payment for the services we provide you. This may include but is not limited to, evaluation reports, treatment notes or other documentation required by your health insurance company or flexible medical spending account. If payment for services is not made as arranged, our office may utilize an outside collection agency, credit reporting agency or other means of collecting outstanding debt. Your file, containing protected health care information, may be reviewed by the designated collection agency or authority.
Appointment reminders: We may use or disclose your child’s health information to provide you with an appointment reminder by text message, voicemail, or email. If you do not wish to have us leave messages about your child’s appointment in a specific manner, please let us know.
Marketing: We will not use your child’s health information for marketing purposes or communications without your written authorization.
Workers’ Compensation: If applicable, we may disclose your health information as necessary to comply with state Workers’ Compensation Laws.
Emergencies: We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care, about your medical condition or in the event of an emergency or of your death.
Public Health: As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.
Required by Law: We may use or disclose your child’s health information when we are required to do so by law.
Abuse or Neglect: We may use or disclose your child’s health information to appropriate authorities if we have reason to believe that your child is a possible victim of abuse, neglect, domestic violence, or other crimes. We may use or disclose your child’s health information to the extent necessary to prevent a serious threat to your child’s safety or health or the safety and health of others.
Law Enforcement/Court Proceedings: We may disclose your health information to a law enforcement official for purposes such as complying with a court order or subpoena. If you are involved in a court proceeding and a request is made for information about the professional services the HSCNC provided you, such information is privileged under California law, and we will not release information without the written authorization of you or your legally appointed representative or a court order. The privilege does not apply when the evaluation is court ordered. You will be informed in advance if this is the case.
Deceased Persons: We may disclose your health information to coroners or medical examiners.
Public Safety: It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public. Our professional staff are mandated by law to disclose health information if the patient/client/student presents a threat to themselves or others.
Your Health Information Rights
· Restriction: You have the right to request restrictions on certain uses and disclosures of your health information. You have the right to request additional restrictions regarding our use or disclosure of your child’s health information. All requests for additional restrictions to your health information must be in writing. Please contact our privacy officer for assistance. We may deny your request under certain circumstances. The law allows us to disclose information without your authorization in response to: a. a court order, subpoena, warrant, or similar process, b. health oversight agencies, c. report about victims of abuse, neglect, or domestic violence, or d. public health activities.
· Alternative Communication: You have the right to have your health information received or communicated at an alternate address or by alternate means (e.g. only by phone or in person), upon your request. All requests for alternative communication regarding your child’s health information must be in writing and specify which location or method you want your child’s health information communicated
· You have the right to inspect and copy your health information.
· You have the right to request that Gold Speech amend your protected health information. Please be advised, however, that Gold Speech is not required to agree to amend your protected health information. We may deny your request if the information: a. was not created by us (e.g. report from another professional), b. is not part of the protected health information we keep, or c. is determined by us to be accurate and complete. If we deny the requested amendment, we will tell you in writing how to submit a statement of disagreement or complaint that can become a part of your child’s record. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial.
· You have a right to receive an accounting of disclosures of your protected health information made by Gold Speech.
· You have the right to a paper copy of this Notice of Privacy Practices at any time upon request.
· Your authorization: In addition to our use and disclosure of your child’s health information about your child for treatment, payment, and healthcare operations, we may use your information for other purposes with your written authorization (email permission acceptable), such as recording video clips for parent feedback. You may revoke this authorization at any time with a written request. Revoking your authorization will not affect any use or disclosures permitted by your authorization while it was in effect. We cannot use or disclose your child’s health information for any reason except those described in this notice without your written authorization.
Changes to this Notice of Privacy Practices
Gold Speech reserves the right to amend this Notice of Privacy Practices at any time in the future, as permitted by federal and state law, and will make the new provisions effective for all information that it maintains. Until such amendment is made, Gold Speech is required by law to comply with this Notice. If changes are made, the new notice will be posted at our site. A paper copy of any such amended notice will be made available upon request.
Gold Speech is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice, or if you want more information about your privacy rights, please contact Gold Speech’s HIPAA Officer, Dawn Gold, by calling (650) 669-8539.
Breaches of Privacy
Gold Speech will contact you via mail in the event of a breach of security that has compromised the privacy of your health information. We will also notify any third party agency that you have authorized to receive such information.
Concerns about your privacy rights or how an SLP at Gold Speech has handled your health information should be directed to the Owner, Dawn Gold, by calling (650) 669-8539.
If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:
DHHS, Office of Civil Rights
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201
We support your right to the privacy of your child’s health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services Privacy.
This notice was last updated on 8/5/2019