______________________________________________________________________________
San Francisco Speech and Fluency Center
______________________________________________________________________________
Bailey V. Levis, MS, CCC-SLP
Speech and Language Pathologist, Lic. SP20591
Office: 415-496-6757
Practice Policies and Consent to Treatment
Welcome San Francisco Speech and Fluency Center! I look forward to supporting you as you
become the best version of you that you can be. This packet contains forms to be completed and
returned by mail or email prior to your initial appointment. Please return all forms by mail or
email one week prior to the evaluation or treatment date. If you have additional information,
such as school or therapy reports, please forward those as well. Should you have any questions
about the completion of these forms, please do not hesitate to call 415-496-6757.
Please make sure to complete the following items to help prepare for the evaluation or initial
session.
➢ Complete this and any other forms provided
➢ Send the completed forms to me at the addresses
➢ Send other relevant reports
Please mail forms to:
San Francisco Speech and Fluency Center
3150 18th St. Suite 466
Mailbox #211
San Francisco, CA 94110
Or email to:
[email protected]
Sincerely,
Bailey V. Levis, MS, CCC-SLP
Owner, San Francisco Speech and Fluency Center
San Francisco Speech and Fluency Center
San Francisco Speech-­‐Language Pathology, Inc
3150 18th St., Suite 466, Mailbox #211 ~ San Francisco, CA, 94110 ~ 415-­‐496-­‐6757
Rev. 02/2017
______________________________________________________________________________
San Francisco Speech and Fluency Center
______________________________________________________________________________
Bailey V. Levis, MS, CCC-SLP
Speech and Language Pathologist, Lic. SP20591
Office: 415-496-6757
Attendance Policy
SFSFC wants to provide the best possible services to all clients. Regular attendance is critical to you
or your child’s progress. Missed appointments and late cancellations also impedes the ability to serve
others. SFSFC will do its best to schedule appointments that meet your needs. Your initials in the
spaces provided confirm that you have read and understood these attendance policies.
1. Attendance: Your child’s scheduled time slot is reserved for you each week. ______
2. Cancellations: In order to avoid cancellation fees, 48-hour notice is required. Cancellations with
less than 48 hours notice will be charged a cancellation fee of $150, unless your session can be
rescheduled within 7 days. _____
3. Sick Policy: If you/your child is not feeling well it will be difficult to focus during our session. If
there are any signs of ongoing infection, including fever over 100o F, vomiting, diarrhea, sinus
infection with green/yellow mucus, etc., or illnesses such as pink eye, strep throat, chicken pox, or
lice you are required to cancel your session until the symptoms pass. As much advanced notice as
possible is appreciated. However, if your child wakes up sick, please call or text me at 415-496-6757
or email [email protected] by 8:00 am. Cancellations due to illness after 8:00 am may
be considered a missed appointment and may be charged a cancellation fee of $150. _____
4. Missed Appointments: If you cancel or do not attend three (3) sessions in a row, your services
will be put on hold until scheduling challenges can be resolved. You may lose your preferred time
slot. If you know you will be away for an extended period (such as Summer Vacation), please inform
me at your earliest convenience to avoid penalties. Extended absences may result in loss of your
preferred time slot. _____
5. Late for Appointments: If you are more than fifteen (15) minutes late for your appointment, I
reserve the right to cancel the appointment and consider it a missed appointment (see Missed
Appointment policy above). If you are late for three (3) or more consecutive sessions, I may put your
services on hold until scheduling challenges can be resolved. _____
6. Clinician Cancellations: If I am not able to attend your appointment, you will be contacted as
soon as possible. Please be sure that I know the best way to reach you. Every effort will be made to
reschedule your appointment in a timely manner. _____
It is your responsibility to keep your regularly scheduled appointments.
To cancel an appointment please call 415-496-6757 or email BaileySFStutteringHelp.com
San Francisco Speech and Fluency Center
San Francisco Speech-­‐Language Pathology, Inc
3150 18th St., Suite 466, Mailbox #211 ~ San Francisco, CA, 94110 ~ 415-­‐496-­‐6757
Rev. 02/2017
______________________________________________________________________________
San Francisco Speech and Fluency Center
______________________________________________________________________________
Bailey V. Levis, MS, CCC-SLP
Speech and Language Pathologist, Lic. SP20591
Office: 415-496-6757
Payment Policy: Insurance Billing
This is an agreement between San Francisco Speech and Fluency Center and you for
payment of services provided. By signing this agreement, you are agreeing to pay for all
services provided to you or your family member. San Francisco Speech and Fluency Center
does not bill insurance companies directly, but will provide a summary of charges that you
can submit to your insurance company for reimbursement. Consult with your insurance
company about reimbursement rates for out of network providers. In some cases a single
case agreement can be established with insurance companies so that services can be covered
as in-network. Please ask me about this if you’d like more information.
Please read the following information carefully.
● Payment is due at the time of service. We accept cash and credit/debit cards,
including HSA or FSA cards.
● We are happy to talk about other payment arrangements, if needed. Talk to us ahead
of time to make payment arrangements.
Past due accounts:
● For accounts that are past due you are expected to pay in full within 15 days of
receiving our bill. Accounts that are more than 15 days past due will be charged a
$25 late fee per week until paid.
● Accounts past due in excess of 2 months will be sent to a collection agency and
therapy will be terminated immediately. You will be responsible for collection costs,
as well as attorney fees and court costs.
Child’s / Adult Client’s Name
I agree to the payment policies outlined above.
Signature
Date
Relationship to Client
San Francisco Speech and Fluency Center
San Francisco Speech-­‐Language Pathology, Inc
3150 18th St., Suite 466, Mailbox #211 ~ San Francisco, CA, 94110 ~ 415-­‐496-­‐6757
Rev. 02/2017
______________________________________________________________________________
San Francisco Speech and Fluency Center
______________________________________________________________________________
Bailey V. Levis, MS, CCC-SLP
Speech and Language Pathologist, Lic. SP20591
Office: 415-496-6757
Acknowledgment That You Have Received The HIPAA Privacy Notice
San Francisco Speech and Fluency Center is required by law to keep your health information
safe. This information may include:
•
•
•
•
•
notes from your doctor, teacher, or other health care provider
your medical history
your test results
treatment notes
insurance information
I am required by law to provide you with a copy of SFSFC’s privacy notice. This notice tells you
how your health information may be used and shared. It also tells you how you can look at and
comment on your information, and what you can do if you have any concerns regarding your
privacy rights.
By signing this page, you acknowledge that you have been offered a copy of SFSFC’s
privacy notice. The Notice of Privacy Policy can also be found on my website at
www.SFStutteringHelp.com/client-forms/
Print Patient’s Name
Date
Patient or Parent/Guardian Signature
Relationship to Patient
San Francisco Speech and Fluency Center
San Francisco Speech-­‐Language Pathology, Inc
3150 18th St., Suite 466, Mailbox #211 ~ San Francisco, CA, 94110 ~ 415-­‐496-­‐6757
Rev. 02/2017
______________________________________________________________________________
San Francisco Speech and Fluency Center
______________________________________________________________________________
Bailey V. Levis, MS, CCC-SLP
Speech and Language Pathologist, Lic. SP20591
Office: 415-496-6757
CONSENT TO TREATMENT
I have read these Policies and Procedures, reviewed the current fee schedule, and have had any
and all questions answered. My signature below confirms my agreement to their terms.
Furthermore, by signing below I am providing consent for San Francisco Speech and Fluency
Center and Bailey V. Levis, CCC-SLP to provide speech and language services to me / my child.
__________________________________
Client or Parent/Guardian 1 Signature
_________________________________
Date
__________________________________
Parent/Guardian 2 Signature
_________________________________
Date
Name of Child/Individual Receiving Treatment:_________________________________
Parents or Guardians Names: ________________________________________________
Home Address:___________________________________________________________
Home Phone:_______________
Business Address:_________________________________________________________
Business Phone:_____________
Cell Phone:_________________
Email Address:_________________________________
Emergency Contact (Name and Phone):________________________________________
San Francisco Speech and Fluency Center
San Francisco Speech-­‐Language Pathology, Inc
3150 18th St., Suite 466, Mailbox #211 ~ San Francisco, CA, 94110 ~ 415-­‐496-­‐6757
Rev. 02/2017