Information Form
Please complete the Information Form on the following pages as soon as possible and as detailed as possible so we are able to start your file. There is no need to print this form out. Please enter information directly onto this form from your computer, and when you have completed the form in its entirety and hit "submit", it will be emailed to our office.
Other Documents (if applicable)
Please fax (858) 746-4113 or email [email protected] us a copy of any prior Speech/Language, OT, PT, Psychological, dental/orthodontic evaluations or reports (including IEPs or any other pertinent reports) that you have had, if applicable. If applicable, this will be important for us to receive before we begin our speech/language, myofunctional, OT, or academic evaluation or therapy.
Office Locations
We have two offices, one in Carmel Valley and one in Mission Beach. We also offer virtual sessions.
Carmel Valley Office
Our Camel Valley office address is: 12526 High Bluff Drive, Suite 300, San Diego, CA 92130 . We are located in Suite 300, which is on the 3rd floor, immediately to the right when you exit the elevator. You can wait in the lobby reception area for suite 300. The person up front at the desk will direct you where to go, or the therapist will come to get you at the time of your appointment. ***NOTE: If you have an appointment after 6:00 pm, the front doors to the building may be locked, however please do not worry, as the therapist will meet you at the front door to the building at time of your appointment.***
Mission Beach (located inside Water and Sports Physical Therapy)
Our address in Mission Beach is: 2999 Mission Blvd Unit 101 San Diego, CA 92109. Note: our office is located inside Water and Sports Physical Therapy. Water and Sports Physical Therapy is just past the Belmont Park parking lot, across the street. You will see the blue painted wall on the outside of the building. You can park next to the building (in the parking lot next to the blue painted wall), on the street, or in the large parking lot adjacent to the building. When you enter the office, please check in with the receptionist at the front and she will direct you where to go. Your therapist will come to get you at the start of your appointment time.
Payments
We will keep your credit card securely on file for payment for sessions. See the details below for speech therapy, occupational therapy, and myofunctional therapy (self-pay evaluations, and insurance covered vs. out-of-network therapy sessions). If you are a self-pay patient, your credit card will automatically be charged by our office after the session or the next business day. If you have any questions about payments/finances, please contact our Office Manager, at (858) 488-4810 or email [email protected]. Please do not discuss any payment questions with the therapist, as our therapists are solely responsible for the care and treatment of you.
Speech Therapy & Occupational Therapy Out-Of-Network Payment Details
For speech therapy and occupational therapy, we are not an in-network provider, meaning that we do not accept or bill insurance, and we are considered "out-of-network" for insurance companies. You are expected to pay us in full for each session. However, we are able to provide you with an insurance receipt ("Superbill") that has the insurance codes for your sessions. You can then submit this Superbill to your insurance on your own accord to seek reimbursement according to your "out-of-network" insurance benefits. Please let our office manager know if you would like her to send you the Superbills, and she can do so on a monthly basis. Although we are not in-network with insurance for speech or occupational therapy services, many insurance companies will apply a portion of your payment to your out-of-network insurance deductible or will reimburse you according to your out-of-network benefits. NOTE: if you are seeking myofunctional therapy with our speech therapists, your insurance will view the sessions as out-of-network "speech therapy" (they do not recognize the service of myofunctional therapy, but on our Superbill it will appear as "speech therapy" codes). You may also potentially apply these charges towards your FSA. Please contact your insurance company for details. We are not responsible for working with insurance companies or for any insurance reimbursements to you. This next section describes in detail our payment and insurance policy for speech and occupational therapy sessions. Please sign the section at the bottom showing you understand the policy.
San Diego Center For Speech Therapy Payment and Insurance/Superbill Detailed Description
NOTE: If you are seeking Myofunctional Therapy services and you have insurance, please see the section below titled FOR MYOFUNCTIONAL THERAPY PATIENTS INTERESTED IN ACCESSING MYOFUNCTIONAL THERAPY TREATMENT IN-NEWORK WITH THEIR INSURANCE.
San Diego Center for Speech Therapy (SDCST) does not accept insurance for payment of services. You will be considered a self-pay patient. However, some of the services you receive may be covered under your insurance plan (e.g., “out of network” speech therapy) and you could submit information to your health plan for recoupment of some of the portion you will pay SDCST out of pocket.
If you have commercial or Federally funded health coverage, recouping monies from your health plan will work in the following way:
- You will pay SDCST out-of-pocket for treatment
- SDCST will provide you with a superbill that lists procedure codes and diagnosis codes for your sessions.*
- The superbill provided to you can be sent into your health plan for the insurance allowable recoupment.
- Any monies received back from insurance belong to you.
* NOTE: Not all portions of your session have a “procedure code” associated with them. This would mean that portions may be considered “non-coverable” by your insurance and may not be able to be recouped so there will not be a selection on the superbill for these portions. Possible non-covered services by some insurance companies may include but not limited to, myofunctional therapy, experimental or investigative techniques, services without objective measurements, services for maintenance. We are able to use speech therapy codes for myofunctional therapy assessments and treatments, but some insurances may not cover a full amount of such services.
You have put your trust in SDCST to bring about the best successes for you or your child. You will want SDCST to utilize the best treatments for you or your child, and not just those covered by insurance. SDCST has opted not to take insurance because of the unfair restrictive nature of insurance and what would be allowed with insurance is not what is the best treatment.
Tricare
Additional Agreement for Tricare beneficiaries: SDCST does follow the Champus Maximum Allowable Fee Schedule regulations and the prices collected from you at the start of treatment have already taken into consideration the maximum allowable you can be charged on “covered services”. As mentioned in the (*) segment above, not all portions you pay out of pocket are “allowed” by your insurance however we will want to utilize these services in you or your child’s sessions. This document states that SDCST will treat you or your child with all services necessary even though they are not all reimbursable by Tricare.
Myofunctional Therapy Payment Details
We may accept your insurance for myofunctional therapy treatment sessions! This next section describes in detail our payment and insurance policy for myofunctional therapy sessions. Our Myofunctional Therapy assessments are always done by our Speech-Language Pathologists and are considered "out-of-network speech therapy" services (self-pay). After the assessment, some patients are eligible for the Myofunctional Therapy treatment sessions to be done by the Doctors of Physical Therapy that we work with who are also Myofunctional Therapists. These Physical Therapists are in network with nearly all PPO/POS insurances and can bill your insurance directly if you are eligible. Otherwise, you can continue to receive the Myofunctional Therapy with our Speech-Language Pathologists who are not in network with insurances (self-pay, and they can continue to provide you with the out-of -network speech therapy insurance superbill if you would like).
FOR MYOFUNCTIONAL THERAPY PATIENTS INTERESTED IN ACCESSING MYOFUNCTIONAL THERAPY TREATMENT COVERED BY THEIR INSURANCE:
If you have an insurance that our affiliated physical therapy company Water and Sports Physical Therapy, Inc. (Mission Beach/Poway) accepts, you may be able to access our myofunctional therapy treatment services utilizing your in-network insurance benefits. This does not apply to most HMO patients. Please speak with our office manager to determine which insurances our Myofunctional Therapist/Doctor of Physical Therapy at Water and Sports Physical Therapy (Mission Beach/Poway offices) accepts.
If you intend to receive your myofunctional therapy treatment services utilizing your in-network insurance benefits through our affiliated physical therapy company, please note that your initial assessment will be done by our speech therapy company, which is not in network with any insurances. The initial assessment is self-pay, however we can provide you with an insurance superbill to seek reimbursement for this assessment as to your out-of-network speech therapy benefits. See the section above: San Diego Center For Speech Therapy Payment and Insurance/Superbill Detailed Description.
After your initial assessment by our Speech-Language Pathologist and Certified Orofacial Myologist from our speech therapy company, if you have insurance that Water and Sports Physical Therapy accepts and there is medical necessity for physical therapy, you can have your PT/myofunctional therapy treatment sessions at the Mission Beach or Poway offices with our Doctor of Physical Therapy, as per your insurance benefits for PT. Sometimes they are able to do virtual/telemedicine appointments as well. For patients under the age of 5, the ability to receive Myofunctional Therapy by the Physical Therapists will be determined on a case-by-case basis.
If at any point your insurance does not cover your treatment, you can continue your myofunctional therapy with the physical therapist or one of our other Myofunctional Therapists as a self-pay patient and we can provide you with insurance superbills accessing our services as “out of network” providers. NOTE: As a self-pay (non-insurance patient), you are responsible for paying our office directly 100% of the session cost, and we are not responsible for any amount your insurance does not cover if you were to submit a superbill.
Please note that we only have the ability to treat you as an in-network insurance patient (directly billing your insurance according to the above listed description) if you are seen by our Doctor of Physical Therapy/Myofunctional Therapist, and it has been determined that your insurance will cover the services. We will need a referral with medical diagnosis codes from an MD, DO, chiropractor, dentist, or orthodontist within the first 45 days or 12 visits (whichever comes first) of the PT treatment. If you have Medicare, this is required before the first PT visit.
NOTE: Our Speech-Language Pathologists who are Certified Orofacial Myologists are not in-network with insurances, and you would be a self-pay patient given insurance superbills if treated by them at any time. Moreover, our PTs who are Myofunctional Therapists are able to treat you as a self-pay patient if they do not accept your insurance or if your insurance does not cover the services.
It is extremely important for you to understand that if you are being treated for myofunctional therapy by the physical therapists, your myofunctional therapy treatment plan may continue beyond your insurance coverage, and if for some reason you no longer qualify for insurance coverage, we strongly encourage you to continue your treatment until the therapist determines it is not longer necessary, even though you may have to pay out-of-pocket. The completion of treatment is determined by your therapist and should not be determined by insurance coverage. In order to have success in myofunctional therapy, the sessions typically entail 8-10 visits of a “Learning Phase” where we teach you the exercises and correct functioning, and then you continue on a monthly basis until treatment goals have maintained and stabilized at an unconscious level (i.e., until carryover on a daily basis, day and night, outside of the therapy session is achieved). Terminating therapy early can result in the loss of achieved skills and failure in ultimately achieving therapy goals. It is a benefit that we may accept your insurance, but we hope you will commit to therapy regardless of your insurance status. Please sign the area at the bottom showing that you understand the policy of our Myofunctional Therapy services.
Missed Visits/Cancellation Policy
If you ever need to cancel/change your session, please call us at least 24 hours in advance. You may call or text our office manager at (858) 488-4810 to cancel a session. A phone call or text message is the quickest and most efficient way to cancel a session. Our missed visit fee is as follows: The fee for a no-show or cancellation of an evaluation with less than 24 hour notice is $100.00. For therapy sessions, the 1st no show or late cancellation is $50.00; 2nd and subsequent no shows or cancellations will be charged the full rate of the session that day. We may need to remove you from our schedule if there are more than 3 missed visits due to a late cancellation or no show. We understand that life happens and will handle those instances on a case-by-case basis. The time slot that you have chosen is reserved solely for you. We do not double-book patients and are unable to add a patient who is on our waiting list to a cancelled session when we are given less than 24 hours notice. We thank you for your understanding of our cancellation policy.
Please sign below that you understand the process for payment of services received by SDCST including payment policy, insurance, and cancellation policy, and that you have had the chance to ask all questions concerning the above information. By typing your name here you are agreeing to the above terms. This field is equivalent to a hand-written signature.
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