FULP THERAPY SERVICES, INC. - Communication Specialists for Children
Payment Policy
 
This is to inform you that payment is expected at the time services are rendered, unless payments are made in advance with our business office.
 
Fulp Therapy Services, Inc. will bill your insurance company for speech therapy services rendered, however you are ultimately responsible for any amounts not covered by your insurance company.  Generally insurance companies will cover speech therapy for a medical diagnosis.  When services are billed to the parents, full payment is expected upon receipt of the bill.
 
Cancellation/Tardiness Policy
 
Due to the overwhelming need for our services, it is our policy to discharge those clients who are unable to make the necessary commitment to therapy.  A client will be discharged after the third absence without advance notification (cancellations not made 18 hours ahead of time) or when attendance has dropped to 50% in any 30 day period.  We reserve the right to charge for any cancellations not made 18 hours in advance.  You will be responsible for this charge.  Your insurance company will not pay for it.  If you know you are unable to attend your regularly scheduled session(s) in advance, we can make the necessary adjustments to our schedules.
 
Any client arriving late to his/her scheduled appointment will lose that time from his/her session or may be asked to re-schedule the appointment.
 
Billing/Collections
 
Occasionally, accounts that become delinquent must be turned over for collections.  This release authorizes Fulp Therapy Services, Inc. to release speech therapy billing records for the purposes of collecting delinquent accounts.
 
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Client Name
 
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Parent Signature                                     Date
 
Notice of Patient Information Practices
 
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUR CHILD MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO INFORMATION. PLEASE READ IT CAREFULLY.
 
Fulp Therapy Services, Inc. is required by law to protect the privacy of your child's personal health inromation, to provide this notice about our information practices and to follow the information practices that are described herein.
 
Fulp Therapy Services, Inc. uses your child's personal health information primarily for treatment, obtaining payment for treatment, conducting internal administrative activities and evaluating the quality of care that we provide to your child.  For example, we may use your child's personal health information to contact you for appointment reminders, for information about treatment and/or other health related benefits that could be of use to you.
 
Fulp Therapy Services, Inc. may also disclose your child's personal health information without prior authorization for public health purposes, auditing purposes, research studies, for emergencies and to our attorneys should it become necessary.  We also provide information when required by law.
 
In any other situation, it is our policy to obtain your written authorization before disclosing your child's personal health information.  If you provide us with a written authorization to release your child's information, you may later revoke the authorization to stop future disclosures at any time. When changes occur to our existing policy, we will post a new Notice of Information of Practices in the waiting room and provide one to you at your next visit.  You may also request a copy at any time.
 
You may also request in writing that we not disclose your child's personal health information for treatment, payment and/or administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances.  We will consider all such requests on a case by case basis, but the practice is not legally required to accept them.
 
If you are concerned that Fulp Therapy Services, Inc. may have violated your rights or if you disagree with any decisions we have made regarding access or disclosure of your child's personal health information, please contact us at the number below.  You may also send a written complaint to the US Department of Health and Human Services.  For further information on our health information practices or if you have a complaint, please contact:
 
Kim Fulp, President
900 Old Winston Rd, Suite 106
Kernersville, NC 27284
336-993-5769
 
I have read and fully understand the Notice of Information Practices.  I understand that Fulp Therapy Services, Inc. may use or disclose my child's personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment/payment.
 
I hereby consent to the use and disclosure of my child's personal health information for the purposes noted above.  I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.
 
Patient Name________________________________________
 
Parent Signature_____________________________________
 
Date_______________________________________________
 
Consent for Evaluation (for children under the age of 3 only)
 
I, ______________________________give my consent for Fulp Therapy Services, Inc. to complete a speech-language evaluation  on my child,__________________________________.  I fully understand that the Winston-Salem CDSA offers this type of evaluation free of charge to children under the age of three years.  By having this evaluation done at Fulp Therapy Services, Inc. I am agreeing to pay for the evaluation in full or for any portion my insurance will not cover.  I understand that my insurance company and/or Medicaid will be billed for this service and any subsequent treatment recommended by Fulp Therapy Services, including but not limited to, co-payments and/or denials for payment, unless the child has been seen through the CDSA evaluation/approval process.  I agree to pay Fulp Therapy Services for all services rendered. ___________ (initials)
 
I further agree to notify Fulp Therapy Services if I decide at a later date to initiate the CDSA process for my child. ______________(initials)
 
I also understand that Fulp Therapy Services is a private entity who does NOT provide speech therapy services through the CDSA.  The CDSA is funded by the state of North Carolina and has very strigent guidelines on which they base recommendations for treatment frequency (which may or may not be the same as our frequency recommendations).  The CDSA utilizes a "teaching model" where the parents are taught how to work with the child to encourage speech-language development rather than a "direct treatment model" where therapy is provided to the child directly (usually 1-2 times weekly)________________(initials)
 
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Parent Signature              Date               Fulp Therapy Services Staff