Insurance Information

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Please correct the errors described below.

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

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    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.


    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

    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

    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

    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 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

    Your information will be encrypted.