Williamsburg Speech Therapy PLLC
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.
The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. HIPAA provides penalties for covered entities that misuse personal health information.
As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.
Treatment means providing, coordinating, or managing health care and related services, by one or more health care providers. An example of this would include a physical examination.
Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collections activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.
We may create and distribute de-identified health information by removing all references to individually identifiable information.
We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.
You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:
The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosure to family members, other relative, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
The right to inspect and copy your protected health information. The right to amend your protected health information
The right to obtain a paper copy of this notice from us upon request.
This notice is effective as of April 14, 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.
You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaints with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the polices and procedures of our office. We will not retaliate against you for filing a complaint.
Please contact the following for more information:
The U.S. Department of Health & Human Services Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
(202) 619-0257
Toll Free: 1-877-696-6775
Thank you for choosing our private practice to serve you. We are committed to providing you with the highest quality care. Please know that the timely payment of your bill is an integral part of our service and as such, this payment policy is an agreement between you and Williamsburg Speech Therapy PLLC for payment of services provided. By signing this policy, you are agreeing to pay for services provided to you or your family member. As a client of Williamsburg Speech Therapy you are required to carefully review and sign our payment policy. A Speech-Language Therapy session is $125/30 minutes. A speech-sound evaluation is $170 and a Receptive-Expressive Language Evaluation is $280. A written summary of evaluation results is included in the evaluation costs. Any locations outside of the Greenpoint or Williamsburg area will incur a $50 travel fee per session. All therapy fees (including session fees) are due upon completion of therapy.
We accept the following payment methods at this time: credit card
Upon request, we can provide you with an invoice outlining the services rendered and the amount charged.
Please read and sign to acknowledge understanding and the sign below:
I understand that I am responsible for all costs / fees that any third-party payer (ex. insurance company, private school, etc.) does not cover. In the event that a third-party payer source determines that rendered therapy services are “not covered” or otherwise denied, I will be responsible for all outstanding charges. I understand that I will be billed accordingly and will be responsible for immediate payment. I also understand that Williamsburg Speech Therapy PLLC will not become involved in disputes between you and your third-party source regarding uncovered charges or reasons for denial.
I understand that if fees are not paid in full, treatment sessions may be postponed or cancelled until payment is received.
I understand that I am responsible for all legal and collection fees, which Williamsburg Speech Therapy PLLC may incur if payment is not made in 30 days.
I understand that refunds will be issued only in instances of overpayment. All refunds will be processed within 30 days after the overpayment is discovered on the client’s bill or at the time the refund is requested. Refunds for payments made with a credit card will be credited back to the credit card used.
I understand that all cancellations require 12 hours notice and that there will be a $50 charge for any cancellations made less than 12 hours. This charge is my sole responsibility and will not be covered by a third-party source. I understand the payment policy and the risks of not adhering to it.