Thank you for visiting Motor Mouth Therapy Services. We want your visit to be pleasant and comfortable.Please help us by completing this form
BILLING POLICIES
All insurance claims from treatment received through Motor Mouth Therapy Services (MMTS) are filed as a courtesy to you and are subject to review by your insurance carrier. MMTS will submit a claim with your insurance carrier up to 2 times per appointment and any further insurance appeal is solely your responsibility unless a secondary source of payment is established. This includes, but is not limited to: insurance company denying coverage for any procedure, policy deductibles, policy maximum annual or lifetime benefits being exceeded, insurance paying an amount for a procedure based on its usual and customary benefit schedule which is less than the fees charged by MMTS for such procedure and MMTS not receiving payment within a reasonable amount of time even if you are appealing the denial of insurance benefits by the carrier. In order for us to continue treating your child without stoppage in therapy and to encourage efficient billing and payment processes we request your assistance.
Please be advised that if we are filing with a private insurance company that the turnaround time to get an EOB (explanation of benefits) may be 4-6 weeks or longer. By the time we know whether or not your insurance company will pay, we may have accumulated more than one month's invoice. Please plan ahead as you will be expected to pay the balance on all of the invoices within two weeks of the dated invoice.
Any out of pocket payments not paid IN FULL within 14 days of invoice will incur a minimum $10 or 10% (of total bill) late fee and will continue to accrue an additional 10% of the total invoice each subsequent week the invoice is not paid in full. All checks should be paid to the order of Motor Mouth Therapy Services.
INSURANCE
Prior to your first appointment, Rosario Miranda with HRA Billing Solutions will contact your insurance company to determine your child’s speech benefits. We highly recommend that you contact them as well. Insurance coverage DOES NOT guarantee speech therapy benefits. Benefits are plan-specific.
Your insurance company may request from you the “diagnosis” for your child. Many insurance companies will not reimburse “developmental” diagnoses such as “speech delay”. Diagnoses that are “disorders” or “disturbances” tend to be covered more often.
MEDICAID
We are a Georgia Medicaid Provider for direct bill services such as Social Security Insurance (SSI),The Deeming Waiver programs, Wellcare, Peachstate, and Amerigroup.
*We will not retroactively bill Medicaid for services rendered*
PRIVATE PAY
Payment is due at the time services are rendered.
Any billing questions should be directed to Rosario. She can be reached most easily through her email but feel free to leave her a voicemail and she will return your call as soon as possible.
Rosario Miranda- HRA Billing Solutions
Email: billing@motormouththerapy.com
Phone: 678-820-9606
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Consent for Treatment
I do hereby consent for treatment by Motor Mouth Therapy Services. I consent to the care and treatment falling under the practice guidelines of the American Occupational Therapy Association (AOTA), the American Speech-Language-Hearing Association (ASHA) and the state of Georgia. I acknowledge that there is always a risk of injury with any therapy involving physical activity. I hereby, intending to be legally bound, waive forever all claims for damages against Motor Mouth Therapy, LLC, the owner(s), and the employees/therapists for any and all injuries and losses, including theft, loss of property, or death that I, my son, daughter, or ward may sustain while participating in any and all activities at Motor Mouth Therapy Services.
By signing this form, I acknowledge that I have read and understand the contents and am competent to execute it, or if executed on behalf of another, that I am authorized to execute it on the behalf of that person.
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Release of Medical Information:
I authorize Motor Mouth Therapy Services to release necessary and pertinent medical information to physicians, case managers, insurance companies, Medicaid and the child’s school as needed for my child. I authorize Motor Mouth Therapy Services to obtain pertinent medical information from the patient’s physician, therapists, case managers and insurance companies as needed.
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Permission to Contact School Therapists:
I authorize Motor Mouth Therapy Services to contact my child’s school therapists in order to obtain pertinent information including, but not limited to, IEP’s and evaluations.
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Cancellations and No-shows:
Your child’s therapist will set up a standing appointment time. This time is set aside for your child. We
understand that situations arise that will prevent you from keeping your child’s appointment. In this case we ask that you notify your therapist at least four (4) hours prior to your appointment time.
2 NO SHOWS: Your child is taken off the schedule and you lose your preferred time slot. You must call the office to reschedule to the first available appointment time.
2 Sick Absences: You must bring in a doctor’s excuse to keep your time slot. If you do not have a doctor’s excuse, you will lose your preferred time slot and be given the first available appointment.
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OUR MEMBER CONFIDENTIALITY STATEMENT
We protect the confidentiality of our members’ personal financial and health information as requested by law and accreditation standards and our internal procedures. This Member Confidentiality Statement explains your rights, our legal duties and our privacy
practices.
Your Financial Information
In order to conduct health care activities, we collect and use several different types of financial information. This includes information that you provide directly to us on applications or other forms, such as your name, address, age and information about dependents. We accumulate information about your transactions with insurances companies such as eligibility, coverage and deductibles. We use physical, electronic and procedural safeguards to protect your confidential information. We make it available only to our employees, affiliates or others who need it to service or maintain your account, to conduct insurance transactions and functions, or for other legally permitted or required purposes.
Your Health Information
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.
We collect, use and disclose information provided by and about you for health care operations or when we are otherwise permitted or required by law to do so.
For Payment: We may use and disclose information about you in managing your account and collecting payment for claims for medical care you receive through your plan. For example, we maintain information about your deductible payments and co-pays.
For Health Care Operations: We may use or disclose medical information about you for our operations. For example, we may use information about you to review the quality of care and services you receive. We may, in the case of some health plans, share limited
health information when required by your health insurance company to determine if treatment is medically necessary. Insurance companies that receive this information are required by law to have safeguards in place to protect it from inappropriate uses. As Permitted or Required by Law: Information about you may be used or disclosed to regulatory agencies, such as during audits, licensure or other proceedings; for administrative or judicial proceedings; to public health authorities; or to law enforcement officials, such as to comply with a court order or subpoena. Authorization: Other uses and disclosures of protected health information will be made only with your written permission, unless otherwise permitted or required by law. You may revoke this authorization, at any time in writing. We will then stop using your information for that purpose. However, if we have already used your information based on your authorization, you cannot take back your agreement for those past situations. Under regulations that will be in effect in April 2003, you will have additional rights over your health information. Under the new rules, you will have the right to:
- Send us written request to see or get a copy of information that we have about you, or amend your personal information that you believe is incomplete or inaccurate. If we did not create the information, we will refer you to the source, such as your physician.
- Request additional restrictions on uses and disclosures of your health information. We are not required to agree to these requests.
- Request that we communicate with you about medical matters using reasonable alternative means or at an alternative address, if communications to your home address could endanger you.
- Receive an accounting of our disclosures of your medical information, except when those disclosures are made for treatment, payment or health care operations, or the law otherwise restricts the accounting. We are not required to give you a list of disclosures made before April 14, 2003.
Complaints
If you believe your privacy rights have been violated, you have the right to file a complaint with us, or with the federal government.
Copies and Changes
You have the right to receive an additional copy of this notice at any time. We reserve the right to revise this notice. A revised notice will be effective for information we already have about you as well as any information we may receive in the future. We are required by law to comply with whatever privacy notice is currently in effect. We will communicate any changes to our notice through direct mail and/or
our website.
Contact Information
If you want to exercise your rights under this notice or if you wish to communicate with us about privacy issues or to file a complaint with us, please contact Information and Privacy Security Officer at 678-820-9606.
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Credit Card Charge Authorization Form
The undersigned hereby authorizes Motor Mouth Therapy Services to charge the below-referenced credit card for services rendered and any related expenses. In addition, as per the signed Billing Policies, I understand my credit card will be charged in the event that:
- proper cancellation procedures are not followed as noted on Attendance Policies (one-half of regular
charge for first missed appointment; full fee for any subsequent missed appointments).
- a check is returned for insufficient funds (fee of $25.00).
- services are terminated by either party for any reason. Your credit card will be charged on the date of
termination for unpaid services.
I, the undersigned, further understand it is my responsibility to inform Motor Mouth Therapy Services of any
changes to my credit card information including address, zip code, updated expiration dates, account numbers and security codes. I understand I will be responsible for any bank chargeback fees in the event that this information is not kept up to date.
PLEASE PRINT CLEARLY
Card #:
Expiration Date:
Name as it appears on Credit Card
CVC Code
Complete Billing Address
Please initial next to one
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Preferred Method of Communication
Preferred method(s) of communication:
Address
Preferred Phone #
Preferred Email
Preferred Fax #
If you have authorized Motor Mouth Therapy Services (collectively “Motor Mouth Therapy”) to communicate and correspond with you via e-mail, you acknowledge that Motor Mouth Therapy may transmit personal and confidential information to you regarding your child’s treatment by email over the Internet. Motor Mouth Therapy will use reasonable means to protect the security and confidentiality of e-mail information sent and received; however, Motor Mouth Therapy cannot guarantee the privacy and security of such information. It is your duty to protect your e-mail account, password and computer against access by unauthorized persons. Motor Mouth Therapy will not be liable in the event that you or anyone else inappropriately uses or accesses your e-mail. You agree that should any information sent to you by Motor Mouth Therapy be intercepted or otherwise accessed or modified by any unauthorized third party, you shall fully release, discharge, and hold harmless Motor Mouth Therapy from any damages arising directly or indirectly from such interception or access. You may revoke your authorization for Motor Mouth Therapy to communicate with you by email at any time by written request.
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All information given in this questionnaire is considered strictly confidential and will not be provided to other agencies without your written consent.
Child’s first Name
middle Name
last Name
DOB
Age
Address
Street
City
State/Province
Zip Code
Telephone (home)
(work)
Referral Source
Reason for Referral
Child’s Physician
Other doctors who provide care to this child
Family Background
Mother’s Name
Age
Occupation
Education Level
If “Yes,” please explain.
Father’s Name
Age
Occupation
Education Level
If “Yes,” please explain.
Brothers and Sisters
| Name |
Age |
Speech, Hearing, or Medical Problems |
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Is there a family history (parents, brothers, sisters, aunts, uncles, cousins, grandparents) of any of the following?
Who is currently living in the home with your child?
Have there been any of the following major changes in the family during the last year?
Statement of the Problem
Describe in your own words the nature of your concerns about your child’s development.
When did you first notice this problem?
What information do you hope to gain from this evaluation, and what specific questions or areas do you wish to address?
Educational History
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Location/School |
Teacher(s) |
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How often does your child attend classes?
What type of classroom is your child in? (i.e., traditional, open classroom, transdisciplinary, etc.)
Is your child classified by the school district to receive special education and/or related services?
Yes
No
If yes, please explain:
Date of Classification:
Type of Classification:
Date of Last Re-evaluation:
Type of Services (self-contained class, resource room, in-class support):
Name of Case Manager:
Phone #:
Has your child ever been evaluated for or attended therapy for:
Please give locations, dates, and results.
Please provide any additional information you feel might be helpful in evaluating your child.
Thank you for your help. Your insights will enable us to do our best for you!
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RELATIONSHIP TO CLIENT |
This checklist was designed to be a quick screening tool for sensory processing deficits. Please indicate if your
child always responds or greater than 50% of the time responds. If several items are checked throughout many
categories or most items are checked in one category, sensory processing deficits may be present.
