New Patient Information Form (Child)

Welcome to San Diego Center For Speech Therapy, Myofunctional Therapy, Occupational Therapy, & Educational Services. We are delighted that you have chosen us to be the providers of your therapy. This packet must be entirely completed and submitted electronically to us before any services are scheduled. You are able to hit "save" and complete filling out this form at a later time, but the form will NOT be sent to us until you complete it entirely and hit "submit" at the end of the form. It is estimated that this form will take you about 20-30 minutes to complete. If for any reason you are not able to easily access this online form, please contact out office ASAP, and we can email you a PDF version or send you a hard copy that you can fax/email back to us before your appointment.

1. General Information with details about our clinics.

2. New Patient Information Form in order for us to obtain information about you. Please type your answers onto this form. We appreciate your thoroughness in answering all of the questions on the Information Form

3. Authorization To Exchange Information Section to allow us to contact your physician, psychologist, dentist, orthodontist, teacher or any other specialists that may pertain to our therapy and your progress. Please electronically sign the bottom of this form.

4. Photo/Video Permission Section. We will take pictures of you as baseline measures and to show progress in therapy. You additionally have the option to allow us to potentially use a photograph/video on our website, brochures, or during educational lectures to other related professionals so other patients and professionals are able to see the progress that our clients make in therapy. We appreciate your permission, as this helps others understand how truly beneficial speech therapy, myofunctional therapy, and OT really are. Please check the appropriate boxes and electronically sign the bottom of this form.

5. Credit Card Authorization Section to be used for all payments. Please contact our office manager at 858-488-4810 to provide her with your entire credit card number. As part of our general procedures, your credit card will automatically be charged after every session or the next business day. Your credit card information given to our office manager is secure and confidential. We will need some basic credit card information verified on this form, including the last 4 digits of your credit card. Please do not forget to electronically sign this form, as you must complete this form for any sessions to occur. We will need your credit card information to hold your place for sessions. You will not be able to submit this packet without signing. For SD Regional Center patients, we need your credit card information as part of our cancellation policy as well. We currently accept Visa and Mastercard.

6. Assessment Pre-Pay Charge. As explained to you over the phone or in your prior communication with our office upon booking, for any Speech/Myofunctional Therapy Evaluations, there is a $50 Assessment Pre-Pay Charge at the time of the booking that will be applied to the $500 evaluation cost. Therefore, at the time of the assessment you will be charged the remaining $450. For any Full Speech & Language Evaluations, there is a $100 Assessment Pre-Pay Charge at the time of booking that will be applied to the $800 evaluation cost. Therefore, at the time of the assessment you will be charged the remaining $700. This Assessment Pre-Pay Charge is not refundable. If you do need to reschedule the assessment, we need at least 24 hours’ notice, and the Assessment Pre-Pay Charge can be applied to a rescheduled appointment only one time. If you give <24 hours’ notice or do not show to the appointment, then this pre-pay charge will not be applied to a rescheduled appointment, and the next assessment booking will be the full cost of $500 or $800, depending on which type of evaluation was booked. We will also need to collect another Assessment Pre-Pay to book another evaluation. We appreciate your understanding of this policy, as we have a very booked schedule and cannot hold 1-2 hours of our therapist's time without the patient commitment to the scheduled appointment, as we have a waiting list of many patients who need to get in for services.

7. Text Messaging Information Form. Several laws in the U.S. regulate communications between businesses and their customers to help reduce robocalls and spam text messages to benefit both the sender and recipient of text messages. The information below is required for us to display for you: 1) privacy policy, 2) terms and conditions page, and a 3) texting opt in consent.

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 Info@SanDiegoCenterForSpeechTherapy.com 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 one main office in Carmel Valley and we also offer virtual sessions in certain circumstances.

Carmel Valley Office

Our Camel Valley office address is: 12544 High Bluff Drive, Suite 300, San Diego, CA 92130 . We are located in Suite 200, which is on the 2nd floor, immediately to the left when you exit the elevator. Please wait in the Suite 200 waiting area and your therapist will come out to greet you at your appointment time. Complimentary coffee, tea, hot chocolate, and fresh water are available in the waiting area. Ample complimentary parking is available. If you have any questions, please call or text us at 858-488-4810.

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 Info@SanDiegoCenterForSpeechTherapy.com. 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:

1. You will pay SDCST out-of-pocket for treatment
2. SDCST will provide you with a superbill that lists procedure codes and diagnosis codes for your sessions.*
3. The superbill provided to you can be sent into your health plan for the insurance allowable recoupment.
4. 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.