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					SHANNON C. LINDSTROM, MA CCC-SLP

Payment Policy – Therapist’s Copy
Although many insurance companies reimburse for speech and language services, this is not guaranteed. In addition, standards for reimbursement vary from company to company. Because this is a small business, payment is expected at time of services, unless arranged otherwise. Initial evaluation fee will be requested in 2 parts; $200 deposit at time of assessment and balance when report and recommendations are provided. Fee: $130/hour or part thereof billed in 15 minute increments. You are billed for the total time required to assess and score tests, conference with parents, and write up the report. One time consultation - customized for each child. Handwritten recommendations are provided. A formal report is not included. Fee: $130/hour or part thereof, billed in 15 minute increments. Therapy Session rates are $130/hour. This rate is pro-rated based on the length of the session. A 30 minute session is $65; a 45 minute session is $97.50. Additional travel charges may apply. Invoicing/Payment/Paperwork - You will be provided with an invoice at the time of service or at the end of the month, at your discretion. Your credit card will automatically be charged at the time of billing and you will be provided with a receipt. Your invoice will include diagnostic and CPT codes to submit to your insurance company. If any further documentation is required, it will be provided upon request. If an evaluation is required, you will be charged for the time required to complete testing and write-up the evaluation. Although not required by law, insurance companies frequently require a referral from a doctor for services and evaluation. (A simple statement indicating a request for a speech language and/or oral motor feeding evaluation and follow-up treatment on a prescription bland is usually adequate.) You will receive a formal progress report at 23 month intervals for your personal records, upon request. I do not deal with insurance companies directly, but will provide you treatment plans, therapy notes, etc. upon request. Session Policies/Cancellations – Sessions begin promptly at the agreed upon time. If a child is late for a session, the session will still finish on time. Consistency in attending therapy is very important to making progress; additionally I only accept a limited number of clients at any given time. Therefore I have a strict cancellation policy. Cancellations due to anything other than illness must be made at least 48 hours prior to the scheduled appointment. If the session is not cancelled in advance you will be charged in full for the session. Of course illnesses happen; please call me as soon as you know that you or your child will not be able to attend the session due to illness, preferably before 8:00 AM the day of the session. You can always leave a message on my cell phone at any time, 301-233-3386. It is your responsibility to notify me of any changes in your child’s school schedule (field trips, professional days, closures, etc.). If I don’t receive 48 hours notice and show up at your child’s school, you will be charged. I allow 1 cancellation per month provided proper notice is given (this includes school closure, vacation, illness, etc.). Beyond that, you will be billed for all remaining sessions in a given month. I will provide up to 2 make-up sessions each month; make-up sessions must be completed within 10 days of the original session. I will do my best to provide a make-up session that works for your child’s schedule. No-shows without a prior notification for any reason will be billed in full and a make-up session will not be offered. In the event that I should need to cancel a session, you will not be charged and it will not count as a cancellation for the month. As I mentioned this is a strict policy, please ask if you have any questions. ___________________________________________ Parent Signature ___________________________________________ Shannon C. Lindstrom, MA CCC-SLP ________________________ Date _______________________ Date

8000 HAMILTON SPRING ROAD • BETHESDA, MD • 20817 TELEPHONE: 301-233-3386

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Payment Policy – Parent’s Copy
Although many insurance companies reimburse for speech and language services, this is not guaranteed. In addition, standards for reimbursement vary from company to company. Because this is a small business, payment is expected at time of services, unless arranged otherwise. Initial evaluation fee will be requested in 2 parts; $200 deposit at time of assessment and balance when report and recommendations are provided. Fee: $130/hour or part thereof billed in 15 minute increments. You are billed for the total time required to assess and score tests, conference with parents, and write up the report. One time consultation - customized for each child. Handwritten recommendations are provided. A formal report is not included. Fee: $130/hour or part thereof, billed in 15 minute increments. Therapy Session rates are $130/hour. This rate is pro-rated based on the length of the session. A 30 minute session is $65; a 45 minute session is $97.50. Additional travel charges may apply. Invoicing/Payment/Paperwork - You will be provided with an invoice at the time of service or at the end of the month, at your discretion. Your credit card will automatically be charged at the time of billing and you will be provided with a receipt. Your invoice will include diagnostic and CPT codes to submit to your insurance company. If any further documentation is required, it will be provided upon request. If an evaluation is required, you will be charged for the time required to complete testing and write-up the evaluation. Although not required by law, insurance companies frequently require a referral from a doctor for services and evaluation. (A simple statement indicating a request for a speech language and/or oral motor feeding evaluation and follow-up treatment on a prescription bland is usually adequate.) You will receive a formal progress report at 23 month intervals for your personal records, upon request. I do not deal with insurance companies directly, but will provide you treatment plans, therapy notes, etc. upon request. Session Policies/Cancellations – Sessions begin promptly at the agreed upon time. If a child is late for a session, the session will still finish on time. Consistency in attending therapy is very important to making progress; additionally I only accept a limited number of clients at any given time. Therefore I have a strict cancellation policy. Cancellations due to anything other than illness must be made at least 48 hours prior to the scheduled appointment. If the session is not cancelled in advance you will be charged in full for the session. Of course illnesses happen; please call me as soon as you know that you or your child will not be able to attend the session due to illness, preferably before 8:00 AM the day of the session. You can always leave a message on my cell phone at any time, 301-233-3386. It is your responsibility to notify me of any changes in your child’s school schedule (field trips, professional days, closures, etc.). If I don’t receive 48 hours notice and show up at your child’s school, you will be charged. I allow 1 cancellation per month provided proper notice is given (this includes school closure, vacation, illness, etc.). Beyond that, you will be billed for all remaining sessions in a given month. I will provide up to 2 make-up sessions each month; make-up sessions must be completed within 10 days of the original session. However, please be advised that make-ups are at set times and may require you to rearrange your schedule in order for your child to attend. Please ask for a list of make-up times. No-shows without a prior notification for any reason will be billed in full and a make-up session will not be offered. In the event that I should need to cancel a session, you will not be charged and it will not count as a cancellation for the month. As I mentioned this is a strict policy, please ask if you have any questions. ___________________________________________ Parent Signature ___________________________________________ Shannon C. Lindstrom, MA CCC-SLP ________________________ Date _______________________ Date

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Release of Information
I authorize the exchange of pertinent information between Shannon C. Lindstrom, MA CCC-SLP and the following professionals for a cohesive multidisciplinary approach. ___________________________________________ Contact Person/Title ___________________________________________ Contact Person/Title ___________________________________________ Parent Signature ________________________ Phone # ________________________ Phone # ________________________ Date

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Credit Card Authorization - Required I authorize Shannon Lindstrom to charge my credit card (check one) _______ after each session _______ after the last session of the month for therapy services rendered to my child/children and for cancellations/no shows not made within the guidelines of the cancellation policy. I understand that all credit card information will be used only in a secured format and will not be shared with anyone other than for the purposes for which it was intended. I understand that I will be provided with an invoice and receipt each time my card is charged. (This may be provided via mail, e-mail, or at the next therapy session.) Name as it appears on card: _____ ____________________________________________ Billing Address of card: _____________________________________________________ ________________________________________________________________________ Card #: _________________________________________________________________ Expiration Date: ______________________ Security Code on card: _________ Home Phone (in case of difficulty processing card): ____________________________ Cell Phone: ________________________________ E-mail: ________________________________________ ____________________________________ Card holder Signature – My signature authorizes use of my card for the above described purposes. I understand and accept the payment policies outlined by Shannon C. Lindstrom. _________________________ Date


				
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posted:11/6/2009
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