Private practitioners know that they need their clients to sign the proper private practice clinic forms BUT…
which forms are essential to decrease our professional, financial and legal risk…?
Keep reading 🙂
We’ve all been told:
“Don’t treat private clients without the proper forms filled out and signed by your client / their families.”
It’s important to be organized and diligent about having the proper client information / permission / acknowledgement forms signed before treatment begins.
1. Intake / Case History Form (Pediatric & Adult)
The intake form allows you to collect information about the client’s developmental, educational, vocational, speech/language/cognition/feeding/swallow etc. history. Ideally, you would send this form to the client in advance and have it filled out and returned before their evaluation.
2. HIPAA Notice (aka Notice of Privacy Practices) and Acknowledgement of Receiving HIPAA Privacy Notice
The first sheet clearly states the responsibilities of the private practice, the uses and disclosures of protected health information as well as the patient’s rights to privacy. The second sheet is a form for the patient to sign that acknowledges that they have seen the HIPAA notice and understand its contents.
3. Authorization to Exchange, Obtain or Release Information Form
This form allows you to share and receive information with other professionals for evaluation and treatment planning purposes.
4. Consent For Services Form
This form gives permission to the private practitioner to complete an evaluation and render appropriate therapy services.
5. Attendance Agreement / Cancellation Policy
This form clearly outlines the attendance, tardiness, cancellation, bad weather, illness, etc. policies, as well as any fees that the client may be responsible for as a result of a missed session.
This form provides consent from parents for you to conduct a screening with their child (to see if they are within normal limits or should be evaluated further).
7. Payment Policy
Detailed form explaining the client’s financial responsibility and payment terms including your fees / rates and payment options.
8. Record of Contacts
This form provides a record of phone calls, e-mails, etc. as well as details about the interaction.
9. Attendance Log (optional – with Payment Information)
This form provides a record of all attended sessions as well as who the payor source for the session was and whether the session was paid or if the payment is pending.
10. Insurance Verification Form
This form collects information about the client’s health insurance, including their primary insurer, secondary insurer, subscriber number(s), co-pay, etc.
If you’re looking for customizable, fillable Word and PDF versions of essential clinic forms for your private practice, click here.
Jena H. Castro-Casbon, MS, CCC-SLP, is a private-practice consultant who has helped thousands of speech-language pathologists start and grow their own private practices through her company, The Independent Clinician. She has written articles for The ASHA Leader and Presented at ASHA Connect (2017).
You’ll find her online in theSLP Private Practice Beginners Facebook Group and in her premium programs, The Start Your Private Practice System and the Grow Your Private Practice Coaching Program.
Jena lives in Boston, MA and is a wife and mama to two young boys.