Gwen’s Speech Therapy        

“Communication is the Key”

        

Gwen Fowler-Berken, MS, CCC-SLP                P:828-371-3940

310 Terrell Road, Franklin, NC 28734                 F:828-369-7497

GA Lic #SLP008575        gwen@gwenspeech.com

NC Lic #8653        www.gwenspeech.com

CONSENT TO TREATMENT and SERVICE / BILLING AGREEMENT

Client’s Name  ___________________________________        Client’s DOB _________________

  1. Therapy services will be provided in one of the following:
  1. Service locations will include the following:
  1. Cancellations less than twenty-four (24) hours notice will be assessed as a no-show appointment.
  2. Three no shows will constitute discharge from services.
  3. Sessions are non-refundable.

Sick Policy

Therapists reserve the right to discontinue therapy sessions if the client presents as ill (i.e.vomiting, fever, etc. ) or if the client is not well enough to continue.  This is necessary in order to provide your child with the best learning experience possible.  A session fee will be assessed for service therapist availability.     _____ Initial

Attendance/Cancellation Policy

 If unable to attend your scheduled appointment, please contact Gwen Fowler-Berken, MS, CCC-SLP  as soon as possible.  Please see above policy on no shows and cancellations less than 24 hours.     _____ Initial

Inclement Weather

If there is a threat of inclement weather, treatments for that day may be cancelled.  Please contact Gwen Fowler-Berken, MS, CCC-SLP prior to arriving for your appointment to assure treatment has not been cancelled.     ____ Initial

Gwen Fowler-Berken, MS, CCC-SLP may be in network or an out of network service provider for speech-language therapy services.  If In network, Gwen Fowler-Berken, MS, CCC-SLP will accept assignment of benefits for those services the insurance will cover .  If it is not covered, parents will be responsible for the invoice for service.  It is important that members understand the specifics of their insurance plan.  While your insurance may cover speech therapy, it may not cover the diagnosis code your child qualifies.  It is important that families understand that we will gather information from the insurance regarding your coverage.  Should your policy or insurance rules change how and what they will cover, parents are responsible for the bill.  Families are responsible for coinsurance, copay, deductibles as specified by individual and family insurance policies.

Services not typically covered by insurance plans include IEP attendance and travel, IEP review, service collaboration team meetings.  Payments not made within 30 days will result in cessation of services.   Checks for “insufficient funds” will receive a nominal fee of $35.00

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Client/Parent/POA Signature                                        Date