New Client Packet

Welcome to Crossroads Therapy Clinic!

The entire staff at Crossroads Therapy Clinic would like to welcome you to our family and thank you for choosing us for your child's needs. It is our goal at CRTC to provide you with outstanding services, support, and education regarding your child.

Our Mission

We strive to create a supportive environment involving parents, therapist, and the client. Whether your child has a minor speech or language problem or a more complex issue, we will develop a comprehensive individualized therapy program to meet each child's needs. Therapist and parents work together as a team to facilitate the child's occupational, speech, language, feeding and overall communication development. Our primary goal is to support the family and improve the quality of life for our client's by providing services in a family-first, supportive atmosphere.

At CRTC we provide families with the benefits of advanced training and strong credentials.

We strive to provide the best support and therapeutic intervention and we value your active involvement in your child’s therapy. CRTC offers occupational and speech therapy services for children of all ages, from infancy through 21 years of age. Using a team approach, we aim to equip children with the skills and resources they need to engage more fully in all aspects of daily lives.

Our therapy team is highly trained in state of the art therapy services and treatment approaches.

We look forward to working with your family.

Thank you!

Crossroads Staff

Dear Parents,

In order to get started with speech therapy services including screening, evaluation, and treatment, we ask that you submit the following initial paperwork to Crossroads Therapy Clinic:

1. A copy of the front and back of the patient’s insurance card.

2. Signed copies of the following forms:

- Payment Policy with credit card - Complaint Procedures

- Cancellation and No-Show Policy - Consent for Release of Information

- Consent to Treat - HIPPA Authorization

- Consent to Video/Photograph - Complaint Procedures

Please complete the Case History Form to the best of your ability. This will help us better understand the needs of your child. You may fax, mail or email the completed and signed initial paper work to Crossroads Therapy Clinic at:

Crossroads Therapy Clinic

1208 N Walnut Ave

New Braunfels, TX 78130

Fax: (830) 214-6660

Email: crossroads@cr-tc.com

We look forward to working with you to facilitate and improve your child’s occupational, speech and language skills. Please do not hesitate to call us at (830) 214-0866 if you have any questions about the required forms or about our speech and occupational therapy services in general.

INSURANCE, PAYMENT POLICY & AGREEMENT

Crossroads Therapy Clinic is currently an in-network provider for Community First Health Plan for Medicaid. If your current insurance provider is CFHP Medicaid, benefits will cover 100% of the payment for the evaluation and therapy. Crossroads Therapy Clinic will bill Medicaid for evaluations and therapy.

Crossroads Therapy Clinic is in network and accepts the following insurances, BCBS, UHC, Champ VA and Tricare. Crossroads is an out-of-network provider for all other private insurance companies. We will be happy to file with your insurance provider on your behalf as an out-of-network provider. Full payment is due at the time services are rendered until an EOB is received showing what your insurance may or may not cover. At that time, should your insurance cover any or all of your services, out of pocket payments may be adjusted accordingly.

PRIMARY INSURANCE

Name, address, phone number of Insurance Company:

Name of Policy Holder

Relationship to client

Policy Holder’s Date of Birth:

Policy Holder’s ID Number:

Patient ID # (if different than Policy Holder’s ID):

Group Number:

Payment must be received on the day services are rendered or will be billed to the credit card on file.

Copayments are due at the time of service.

Coinsurance is calculated and also due at the time of service.

Prior Authorization may be necessary after an evaluation or certain number of visits as required by your insurance company. We will work with your insurance company to get this in place. However, if you change insurance carriers, do not tell CRTC, and a prior authorization is required for services, you will be responsible for payment for those denied dates of service.

We require a credit card to be on file at all times for any expenses not covered by your insurance. Reminder: Your credit card will be required upon scheduling initial appointment.

*Returned checks by your bank will incur a $20.00 fee and any additional costs from the bank.

Parents and/or guardians must also notify Crossroads Therapy Clinic if your child’s physician or insurance coverage changes.

As the parent or guardian, I have read the above information and understand Crossroads Therapy Clinic’s Insurance Policies and Authorization to Release Information. I accept all terms and conditions.

Date

Name Parent/Guardian

Signature

CONSENT TO TREAT

Full Name

consent to and authorize Crossroads Therapy Clinic to administer all treatments and services that may be considered advisable in the judgment of my physician and/or therapist in accordance with Crossroads Therapy Clinic policies.

I give permission for my child’s therapist/Crossroads Therapy Clinic to communicate with me regarding therapy sessions (including progress, attendance, scheduling, etc.) via text, and voicemail.

Yes No

Please add Cell Phone Carrier for Text reminders (CARRIER name, not cell number i.e. Verizon)

I give permission for my child’s therapist/Crossroads Therapy Clinic to communicate with me via email regarding therapy. Some emails may include PDF attachments and Word documents which may or may not be password protected.

Yes No

Email Address

I understand that if I want my child’s therapist to communicate with anyone other than the parent/guardian of the child indicated on initial paperwork, I will sign and authorize consent to do so. I will request Crossroads Therapy Clinic to do so in writing.

Parent/Guardian Initials

Name

Signature

Date

CONSENT TO VIDEO OR PHOTOGRAPH AND MEDIA RELEASE

I give my permission for Crossroads Therapy Clinic to videotape and/or photograph a therapy/diagnostic session with my child and use said video/photo for

Promotional Purposes

Teaching Purposes

Photos

MAY BE posted on social media platforms as well as marketing materials MAY NOT BE posted on social media platforms as well as marketing materials

Your child's face may be included in pictures

Yes No

Parent/Guardian Signature

Date

COMPLAINT PROCEDURES AND REPORTABLE CONDUCT

All Crossroads Therapy Clinic employees and contractors will abide by the highest standards of care. Any complaints regarding your care, failure of the agency to provide care, or lack of respect of your property may be reported, without fear of retaliation or discrimination, to a member of the agency’s management, up to and including the administrator, by calling (830)214-0866. If a complaint is reported to the agency, the manager taking the complaint will initiate an investigation. All complaints will be investigated within 10 days of receipt of complaint, and the investigation will be completed and documented within 30 days of the receipt of complaint. The patient or family member will be notified of the outcome when the investigation is complete. Any allegations of abuse, neglect, or exploitation may also be directed to the administrator. You may also report any complaints or gain more information from the Texas Department of Aging and Disability Services at 1-800-458-9858, Monday-Friday from 8:00 AM to 5:00 PM. After hours and on holidays, you may leave a message at the above telephone number for the Department to return your call the next business day. Any reports of abuse, neglect or exploitation may be reported to the Texas Department of Aging and Disability Services at the number above, or the Department of Family and Protective Services at 1-800-252-5400.

Crossroads Therapy Clinic is required by law to report any suspected abuse, neglect, or exploitation to the Department of Family and Protective Services and to law enforcement agencies, if indicated. We will also report any suspected abuse, neglect, or exploitation by a clinic employee or contractor to the Texas Department of Aging and Disability Services and to the Department of Family and Protective Services.

Signature

Date

CONSENT FOR DISCLOSURE OF INFORMATION OR RECORDS

Print Full Name

Do hereby authorize

Name of authorized person/organization

to do the following...

Disclose Information

Obtain Information

Exchange Information

If 'Exchange Information' chosen, please provide on separate lines the name, address, phone number and email of each person/organization that is authorized for exchange of information

Please provide which Protected Health Information is allowed to be shared/exchanged

Please indicate the purpose and need of disclosure

My consent shall expire in 12 months. This authorization may be revoked by me in writing at any time except to the extent that action has been taken already in response to this Consent for Disclosure of Information or Records.

I am aware that information from my record is confidential and protected by Federal and State Law. Federal and State Regulations (42 CFR Part 2 and R.C.W. 71.05, 70.02) prohibit you from making any further redisclosure of these records without my specific written consent, or as otherwise permitted by such regulations.

Client Name

Parent/Guardian Name

Parent Guardian Signature

Date

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT

YOUR PRIVACY RIGHTS

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Crossroads Therapy Clinic is dedicated to ensuring the privacy of your child’s evaluation findings and course of therapy treatment. In serving our patients, we create records regarding treatment and services that are provided in order to have accurate information and ensure the appropriateness and efficiency of treatment services. Federal law requires us to strictly protect any personally identifying information on your child. This notice discloses our policies regarding the storage, use, and sharing of confidential patient information. PLEASE REVIEW THIS NOTICE CAREFULLY.

Crossroads Therapy Clinic, LLC is required by law to keep your health information safe. This information may include:

Notes from your doctor, teacher, or other health care provider

Your medical history
Your test results
Treatment notes
Insurance information

A government rule requires that you get a copy of this privacy notice. This rule is called the Health Insurance Portability and Accountability Act, or HIPPA for short. We will ask you to sign a paper acknowledging that you have been given this notice.

How Your Health Information May Be Used or Shared

We may use your health information without your permission for the following reasons:

1. Treatment: We may share your information with doctors or other health care providers who care for you. For example, if your doctor orders speech therapy, we will share the results of our treatment with that doctor.

2. Payment: We may use and share information about the treatment you receive with your insurance company or other payer to receive payment for therapy services. This may include sharing important medical information. We ma share information to:

a. Get the insurance company’s permission to start treatment

b. Get permission for more treatment

c. Get paid for the treatment you receive

3. Health Care Operations: We may use and share your health information to run the clinic and make sure all patients receive good care. For example, we may use your health information to:

a. See how well our services are working

b. See how well our staff is doing

c. See how we compare to other clinics and private practices

d. Make our services better

e. Help others study health care services

Your health information may also be used or shared without your permission for:

Abuse and Neglect: We may share your health information with government agencies when there is evidence of abuse, neglect, or domestic violence.

Appointment Reminders: We will use your information to remind you of upcoming appointments. Reminders may be sent in the mail, by email, or by phone call or voicemail message. If you do not wish to get reminders, please tell your therapist.

As Required by Law: We will share your information when we are told to by federal, state or local law. We will also share information if we are asked by the police or courts.

Government Functions: Your information may be shared for national security or military purposes. If you are a veteran, your information may be shared with the Office of Veteran’s Affairs.

Information About a Person Who Has Died: We may share information with the coroner, medical examiner, or a funeral director, as needed.

Health - Related Benefits and Services: We may use your information to let you know of other services that might be of interest to you.

Public Health Risks: We may report information to public health agencies as required by law. This may be done to help prevent disease, injury, or disability. It may also be done to report medical device safety issues to the Food and Drug Administration and to report diseases and infections.

Regulatory Oversight: We may use or share your information to report to agencies overseeing health care. This may include sharing information for audits, licensure and inspections.

Threats to Health and Safety: Your health information may be shared if it is believed that it will prevent a threat to your health and safety or the health and safety of others.

Worker’s Compensation: We will share your information with Worker’s Compensation if your case is being considered as a work - related injury.

When Your Permission is Needed to Use or Share Your Health Information

You must give us your permission to use or share your health information for any situation that is not listed on this notice. You will be asked to sign a form, called an authorization, to allow us to share your information. You are allowed to take back this authorization, called revoking authorization, at any time. We will not be able to get the information back that we shared with your permission.

Your Privacy Rights

You have the right to:

Ask us not to share your information: You can ask us not to use or share your information for treatment, payment, or health care operations. You can also ask us not to share information with people involved in your care, like family members or friends. You must ask for limits in writing. We must share information when required by law. We do not have to agree to what you ask.

Ask us to contact you privately: You can ask us to only contact you in a certain way or at a certain place. For example, you may want us to call you but not email. Or you may want us to call you at work and not at home. You must ask in writing.

Loo k at and copy your health information: You have the right to see your health information and get a copy of that information at any time. You have the right to see treatment, medical and billing information. You may not be able to see or copy information put together for a court case, certain lab results, and copyrighted materials, such as test protocols.

Ask for changes to your health information: You can ask us to change information that you think is wrong. You can also ask that we add information that is missing. You must ask us in writing and give us a reason for the change. We do not have to make the change.

Get a report of how and when your information was used or shared: You can ask us to tell you when your information was shared and who we shared it with. There are some rules about this:

o You need to ask us in writing.

o You must tell us the dates you are asking about and if you want a paper or electronic copy.

o You may get information going back six (6) years, but it cannot be for earlier than April 14, 2003. This is the date when the government privacy rules took effect.

Get a paper copy of this privacy notice: You can get a paper copy of this notice at any time.

File complaints: You can file a complaint with us or with the government if you think that…

o Your information was used or shared in a way that is not allowed

o You were not allowed to look at or copy your information

o Any of your rights were denied

Who is Covered by This Notice

The people that must follow the rules of this notice are:

All speech - language pathologists, occupational therapists, and physical therapists at Crossroads Therapy Clinic, LLC.

Anyone who is allowed to add health information to your file, including students and other staff

Any volunteers who may help you while you are at this clinic/private practice

Changes to the Information in This Notice

WE may change this notice at any time. Changes may apply to information we already have in your file and any new information. Copies of the new notice will be available from our staff. The notice will have a date on the front page to tell you when it went into effect.

Complaints

You may file a complaint if you think we did something wrong with your information. You can complain to your regional office of the United States Office of Civil Rights. All complaints must be in writing. You will not get in trouble for filing a complaint.

Contacts

If you have any other questions about this notice or your privacy rights, please ask your therapist.

I HAVE READ AND UNDERSTAND THE PRIVACY POLICIES DISCLOSED IN THIS NOTICE.

Parent/Guardian Signature

Date

Acknowledgement That You Received Your Privacy Notice

Crossroads Therapy Clinic, LLC is required by law to keep your health information safe. This information may include:

Notes from your doctor
Your medical history
Your test results
Treatment notes
Insurance information

We are required by law to give you a copy of your privacy notice. Please retain a copy of this privacy notice for your records. This notice tells you how your health information may be used or shared. It also tells you how you can look at and comment on your information.

By signing this page, you are saying that you have been given a copy of our privacy notice.

Client Name

Client D.O.B

Parent/Guardian Name

Parent/Guardian Signature

Date