FORMS

Dear Parent(s):

Welcome to Communication Interventions, Inc. We are so pleased that you have chosen us for your child’s speech therapy or mindfulness coaching needs. Be assured that every effort will be made to insure that their experience is both a productive and a pleasant one. Our goal is to support the goals designed for the child and family.  There are a few things that we will need to obtain from you before or at the first scheduled visit. Please download ALL forms. Each page is very important, and therefore we ask that you read them carefully and complete them as accurately as possible. If there is a portion that does not apply, simply enter “NA”. Please review the items listed below, and be sure that we have the items that apply  to our office by your initial visit.
 

Therapy cannot begin unless we have all of the following on file:

• Patient Information Form

• Medical Case History Form

• Assignment of Benefits and Consent to Treat Form (this includes the billing, late fees, insurance, fee schedule, and cancellation policies- PLEASE SIGN AND RETURN)

• Telehealth Consent Form

• ACH/Auto Draft Form

• Rates, Fees, and Policy Agreement (READ ONLY)

• HIPPA Privacy Policy Statement (READ ONLY)

• Copy of insurance card-front and back (if applicable)

• Copy of Medicaid card (if applicable)

• IEP goal page(s) if applicable

BILLING/INSURANCE: At this time, we are in-network providers ONLY with straight Medicaid and Katie Beckett Deeming Waiver clients. We are not accepting Medicaid CMO’s (Amerigroup, Peachstate, Wellcare, etc.) Effective 2/1/2023, our practice will no longer accept patients with Peachstate insurance. If you have out-of-network benefits with a private insurer, we are happy to create a superbill at no charge, or we offer an insurance filing service for an administrative service fee of $10/month

We will be happy to check on benefits and bill your insurance company for you and determine *if* you have out-of-network benefits. However, you are responsible for any unpaid balances or co-pays that your insurance does not cover/pay.  If you have any concerns or questions about this, please review the Rates and Policies Form (see below).

The attached Rates, Fees, and Policy and Policy Agreement and HIPPA Privacy Policy statement are included for your information only and DO NOT need to be returned to us.

Please contact us at anita@speechatlanta.com or call (404)720-4278 if you have any questions.

Sincerely,
The Team at Communication Interventions