Insurance Information

The following is an agreement between The Loop Speech, Language, and Learning, LLC, an Illinois limited liability company, and the Parent/Guardian of the above referenced Patient. As such, all references to the Parent/Guardian or “you,” “your,” or “yours” below means the Parent/Guardian named above.

Insurance Information

You have read and fully understand the above conditions. By signing this agreement, you accept that you are responsible for all payments and charges as stated above. You acknowledge receipt of a copy of this agreement.

Acknowledgement That You Have Received Our HIPAA Privacy Notice

The Loop Speech, Language, and Learning is required by law to keep your health information and
records safe.

This information may include:

• Notes from your doctor, teacher or other healthcare provider
• Medical history
• Test results
• Treatment notes
• Insurance information

We are required by law to give you a copy of our privacy notice. This notice tells you how your health information maybe used and shared.

Please Note: It is your right to refuse to sign this Acknowledgement.

HIPAAA POLICY NOTICE OF PRIVACY PRACTICES (Yours to Keep)

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. HIPPA
provides penalties for covered entities that misuse personal health information.
As required by HIPPA, 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.
HIPAAA POLICY
NOTICE OF PRIVACY PRACTICES
HIPAA
HIPAA


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 filling 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