2025 New Year Paperwork

2025 Patient Update

Please fill in the form below
Patient Name*

First NameMiddle NameLast Name
Have you had any changes to your address?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you had any changes to your phone number?*

YesNo
Phone Number*
Can we text this number ?*

YesNo
Have you had any changes to your email?*

YesNo
Primary E-mail*
This form was completed by: *
First Name, Last Name, Relationship to Patient

Emergency Contact Update

Please list someone other than yourself.
Emergency Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship to the patient*
2nd Emergency Contact*

First NameLast Name
Phone Number*
Relationship to the patient*

Family Update
Does anyone in your immediate or extended family have any medical concerns? (Examples include mental illness, cognitive disability, hearing problems, seizure disorders, etc.)*

YesNo
If yes, please describe:
Are there any family circumstances you feel we should know about? (Examples include a new baby, divorce, separation, recent death in the family, etc.)*

YesNo
If yes, please describe:

Responsible Party

(Parent, Legal Guardian, or Self)
Name*

First NameLast Name
Is the responsible party's address different than the patient's address?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Can we text this number ?*

YesNo

Insurance Information
Will you be using health insurance in 2025?*

YesNo
Financial Agreement and Policies
I understand the speech cash-fee schedule to be as follows: Evaluation $400; Treatment (30 minutes) $130. The ABA cash-fee schedule is as follows: Evaluation $192/hour; Direct Treatment $125/hour; Supervision $125.20/hour; Family training $125/hour.*

I acknowledge
I understand that I may be discharged from Start Bright if more than 40% of scheduled sessions within a 60-day period are not attended.*

I acknowledge
I understand that if I have an outstanding balance of more than 60 days, I will be enrolled in a monthly automatic withdrawal payment plan of 40% of my outstanding balance until the balance falls below $100, at which time the reminder balance will be ran in full.*

I acknowledge
I understand that I am participating in a cash-for-services plan and that my insurance will NOT be billed.*

I acknowledge
I understand that a $50 cancellation fee may be billed to my account if I do not contact Start Bright about cancelling an appointment within at least 2 hours of said appointment.*

I acknowledge
I understand that statements will ONLY be sent to the responsible party.*

I acknowledge

Insurance Information
Have you had any changes to your health insurance?*

YesNo

Name of Insurance Company*
If you do not see your insurance company listed, please speak with your therapist.
Contract Number*
Group Number*
Policy Holder*

PrefixFirst NameMiddle NameLast Name
Policy Holder's Date of Birth*

MonthDayYear
Date
Relationship to Patient*
Employer*
Picture of the front of insurance card

Browse Files

Cancelof
Picture of the back of insurance card

Browse Files

Cancelof

Do you have a secondary insurance?*

YesNo

Name of Insurance *
If you do not see your insurance company please speak with your therapist.
Contract Number*
Group Number*
Policy Holder*

PrefixFirst NameMiddle NameLast Name
Relationship to patient*
Employer*

Primary Care Physician
Have you changed your primary care physician?*

YesNo

Primary Care Physician's Name*
Phone number*
Clinic Name*
Clinic Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Permission for "Remind" App

Remind is a communication platform that helps people stay in touch. It is a free app available in the App Store for iOS and Google Play Store for Android. Remind will be used to communicate with families for important reminders and announcements, such as closures due to inclement weather. We can also send pictures and messages about your child's day.
Please select an option below*

Yes, I give my permission to be added to Remind for therapy-related announcements.No, I do not wish to be added to Remind for therapy-related announcements.

Additional Consent
Visitor Confidentiality
- I understand that during my visits to Start Bright, I may encounter information that I should consider private and confidential. This information may include names of other children enrolled with us. If I share information about my experience at Start Bright, I will shield the identity of these idividuals.
Observation of Therapy
- I give permission for members of the Start Bright staff (including, but not limited to, supervisors, students, technicians, and guest therapists) to observe my child's assessment and/or therapy services.
Mandated Reporters
- I understand that employees of Start Bright are mandated by law to report suspected abuse and/or neglect to their supervisors and the appropriate state/local authorities.
Policy Against Harassment
- Start Bright has a strict policy against all types of harassment. This includes harassment based upon race, national origin, ancestry, religion, gender, sexual orientation, physical or mental disability, veteran status, or any other status protected by federal, state, or local laws. All forms of harassment of or by employees, vendors, visitors, customers, and clients is strictly prohibited and will not be tolerated.
Notification of Recipient Rights
- The Office of Recipient Rights (ORR) was created and is responsible for investigating, resolving, and assuring remediation of apparent, suspected, or substantiated rights violation and assures that all mental health services are being provided in a manner which respects and promotes the rights of recipients. If you ever feel your rights have been violated or would like to learn more, you can reach out to the Michigan ORR office at (517) 373-2319.
Communication
- I understand Start Bright will use multiple methods of communication to contact families. This includes voice calls, text messages, emails, and standard mail. Although it is possible to "opt out" of some forms of communication, I am still responsible for providing the staff with reliable contact information.
Initial Below*

Health and Wellness Policy

Anyone presenting with the following symptoms should not come into the clinic:
- Fever of 100.5° F or higher
- Intestinal problems with diarrhea and/or vomiting
- Any type of undiagnosed rash
- Any type of communicable illness (such as chicken pox, pink eye, measles, impetigo, strep throat, RSV, COVID, lice, hand/foot/mouth disease, fifth disease)
- Congestion or mucus discharge of the eyes, nose, or ears
- Flu symptoms including (but not limited to) two or more of the following: body aches, headache, fatigue, sore throat, chest pains, chills
- Persistent cough and/or difficulty breathing
If a client presents with any of these symptoms, they may be asked to leave our facilities.

This decision will be made at a supervisor's discretion. The supervisor will take all information into account, including new or worsening symptoms, chronic conditions (e.g., allergies, oral sensory issues, and food sensitivities), and temperament of child to make the best decision for the well-being of all involved.

You may return to services when your child:
- Has been fever-free for at least 24 hours
- Free of vomiting, diarrhea, rash, and eye/ear/nasal drainage for at least 24 hours
- Has been taking antibiotics for communicable illness for at least 24 hours
** If your child is absent for 3 or more days due to an illness, please provide a doctor's note clearing them to return to services. **
Initial Below*

Office Hours of Operation and Closure Policy
Hours of Operation:

ABA Therapy:

Monday-Thursday 9am-4pm | Friday 9am-1pm

Speech Therapy:

Monday-Thursday 9am-7pm

**Schedule is subject to change **

Staff/Clinic Cancellation

If a staff member needs to cancel the session for any reason, unless in an instance of unforseen circumstances, there will be advance notice of any cancellation to you as the client. You will be directly notified by the staff member who is scheduled to conduct your session or by administrative staff. For planned absences, both long and short-term, Start Bright will make every effort to provide an alternate staff member for the client's therapy session(s). Should an alternate be covering for the day or should the session need to be cancelled, you will be notified as soon as possible.

Inclement Weather

Our policy is to stay open on all scheduled days, provided we can do so safely. We are not affiliated with any school district, so we may remain open even if schools around us close. Plan on arriving at your normal scheduled time unless you hear differently from administrative staff. If a storm occurs during work hours, we may choose to send people home. If this occurs, management will contact the rest of the scheduled clients and employees for that day to notify them of the cancellation.

Building/Facilities Closure

In the event of a building or facility issue (including but not limited to: power outage, water/sewage failure, and HVAC issue), we will continue to operate if we can do so safely. In the event the issue is expected to be prolonged, we may choose to close the clinic. All clients and employees will be notified as soon as possible if they should not report to the clinic.

Scheduled Holiday Closures

Start Bright recognizes the following holidays. Specifics regarding holiday closure will be communicated ahead of time.
- New Year's Day
- Good Friday
- Memorial Day
- Independence Day
- Labor Day
- Thanksgiving Day
- Christmas Eve
- Christmas Day
Initial Below*

HIPPA Notices
This notice describes how health information about you may be used and disclosed and how you can get access to this information. It is effective April 14, 2003, and applies to all protected health information contained in your health records maintained by us. We have the following duties regarding the maintenance, use, and disclosure of your health records:

We will attempt in good faith to obtain your signed acknowledgement that you received this notice to use and disclose your confidential medical information for the following purposes. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office once you have provided Consent.

Treatment: We will use your health information to make decisions about the provision, coordination, or management of your healthcare, including analyzing or diagnosing your condition and determining the appropriate treatment for that condition. It may also be necessary to share your health information with another health care provider whom we need to consult with respect to your care. These are only examples of uses and disclosures of medical information for treatment purposes that may or may not be necessary in your case.

There are certain circumstances under which we may use or disclose your health information without first obtaining your acknowledgement or authorization. Those circumstances generally involve public health and oversight activities, law- enforcement activities, judicial and administrative proceedings, and in the event of death. Specifically, we may be required to report to certain agencies information concerning certain communicable diseases, sexually transmitted diseases, or HIV/AIDS status. We may also be required to report instances of suspected or documented abuse, neglect or domestic violence. We are required to report to appropriate agencies and law-enforcement officials information that you or another person is in immediate threat of danger to health or safety as a result of violent activity. We must also provide health information when ordered by a court of law to do so. We may contact you from time to time to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend, or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person that is responsible for your care of your location, general condition, or death.
(1) We are required by law to maintain the privacy of the protected health information in your records and to provide you with this notice of our legal duties and privacy practices with respect to that information.
(2) We are required to abide by the terms of this notice currently in effect.
(3) We reserve the right to change the terms of this notice at any time, making the new provisions effective for all health information and records that we have and continue to maintain. All changes in this notice will be prominently displayed and available at our office.
There are a number of situations in which we may use or disclose to other persons or entities your confidential health information. Certain uses and disclosures will require you to sign an acknowledgement that you received this notice of privacy practices. These include treatment, payment, and health care operations. Any use or disclosure of your protected health information required for anything other than treatment, payment, or health care operations requires you to sign an authorization. Certain disclosures that are required by law, or under emergency circumstances, may be made without your acknowledgement or authorization. Under any circumstance, we will use or disclose only the minimum amount of information necessary from your medical records to accomplish the intended purpose of the disclosure.
Payment: We may need to use or disclose information in your health record to obtain reimbursement from you, from your health insurance carrier, or from another insurer for our services rendered to you. This may include determinations of eligibility or coverage under the appropriate health plan, pre-certification, and pre-authorization of services or review of services for the purpose of reimbursement. This information may also be used for billing, claims management and collection purposes, and related healthcare data processing through our system.

Operations: Your health records may be used in our business planning and development operations including improvements in our methods of operation and general administrative functions. We may also use the information in our overall compliance planning healthcare review

This is for your records. You do not need to bring this to your appointment.
Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your healthcare.

Communication Barriers and Emergencies: We may use and disclose your protected health information if we attempt to obtain consent from you but are unable to do so because of substantial communication barriers and we determine, using professional judgment, that you intend to consent to use or disclosure under the circumstances. We may use or disclose your protected health information in an emergency treatment situation. If this happens, we will try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If we are required by law or as a matter of necessity to treat you, and we have attempted to obtain your consent but have been unable to obtain your consent, we may still use or disclose your protected health information to treat you.

Except as indicated above, your health information will not be used or disclosed to any other person or entity without your specific authorization, which may be revoked at any time. In particular, except to the extent disclosure has been made to governmental entities required by law to maintain the confidentiality of the information, information will not be further disclosed to any other person or entity with respect to information concerning mental health treatment, drug and alcohol abuse, HIV/AIDS, or sexually transmitted diseases that may be contained in your health records. We likewise will not disclose your health record information to an employer for purposes of making employment decisions, to a liability insurer or attorney as a result of injuries sustained in an automobile accident.

You may file a written complaint to us or to the Secretary of Health and Human Services if you believe that your privacy rights with respect to confidential information in your health records have been violated. All complaints must be in writing and must be addressed to the Privacy Officer (in the case of complaints to us) or to the person designated by the U.S. Department of Health and Human Services if we cannot resolve your concerns. You will not be retaliated against for filing such a complaint. More information is available about complaints at the government’s web site, http://www.hhs.gov/ocr/hipaa.

You have certain rights regarding your health record information, as follows:

(1) You may request that we restrict the uses and disclosures of your health record information for treatment, payment and operations, or restrictions involving your care or payment related to that care. We are not required to agree to the restriction; however, if we agree, we will comply with it, except with regard to emergencies, disclosure of the information to you, or if we are otherwise required by law to make a full disclosure without restriction.
(2) You have a right to request receipt of confidential communications of your medical information by an alternative means or at an alternative location. If you require such an accommodation, you may be charged a fee for the accommodation and will be required to specify the alternative address or method of contact and how payment will be handled.
(3) You have the right to inspect, copy, and request amendments to your health records. Access to your health records will not include psychotherapy notes contained in them, or information compiled in anticipation of or for use in a civil, criminal or administrative action or proceeding to which your access is restricted by law. We will charge a reasonable fee for providing a copy of your health records, or a summary of those records, at your request, which includes the cost of copying, postage, and preparation or an explanation or summary of the information.
(4) All requests for inspection, copying and/or amending information in your health records, and all requests related to your rights under this Notice, must be made in writing and addressed to the Privacy Officer at our address. We will respond to your request in a timely fashion. (5) You have a limited right to receive an accounting of all disclosures we make to other persons or entities of your health information except for disclosures required for treatment, payment and healthcare operations, disclosures that require an authorization, disclosure incidental to another permissible use or disclosure, and otherwise as allowed by law. We will not charge you for the first accounting in any twelve-month period; however, we will charge you a reasonable fee for each subsequent request for an accounting within the same twelve-month period. (6) If this notice was initially provided to you electronically, you have the right to obtain a paper copy of this notice and to take one home with you if you wish.

All questions concerning this Notice or requests made pursuant to it should be addressed to: PRIVACY OFFICER, Start Bright, 50 Kirts Blvd., Ste. G Troy, MI 48084

HIPAA Notice of privacy practices:2019
I acknowledge I have received a copy of my HIPPA rights.
I understand that if I would like a hard copy of my HIPAA rights, I can ask my therapist at any appointment.

Consent for Purposes of Treatment, Payment, and Healthcare Operations

In this document, “I” and “my” refer to the patient,and “Speech Language Pathologist ” refers to Halpin and Associates Speech and Language Therapy PLLC. I consent to the use or disclosure of my protected health information by Speech Language Pathologist for the purpose of analyzing, diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Speech Language Pathologist. I understand that analysis, diagnosis or treatment of me by Speech Language Pathologist may be conditioned upon my consent as evidenced by my signature below. I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Speech Language Pathologist is not required to agree to the restrictions that I may request. However, if Speech Language Pathologist agrees to a restriction that I request, the restriction is binding on Speech Language Pathologist.I have the right to revoke this consent, in writing, at any time, except to the extent that Speech Language Pathologist has taken action in reliance on this Consent. My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. I have been provided with a copy of the Notice of Privacy Practices of Speech Language Pathologist and understand that I have a right that Notice 's Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Speech Language Pathologist. The Notice of Privacy Practices for Speech Language Pathologist is also posted in the waiting room at Halpin and Associates Speech and Language Therapy. This Notice of Privacy Practices also describes my rights and duties of the Speech Language Pathologist with respect to my protected health information. Speech Language Pathologist reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office of Speech Language Pathologist and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.
Signature*

Clear
Printed Name *
Relationship to Patient *
Date*

MonthDayYear
Date

To the best of my ability, the information I have supplied is complete and truthful.*
Type Name
E-Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

2025 Patient Update

Emergency Contact Update

Family Update

Medical Update

Responsible Party

Insurance Information

Financial Agreement and Policies

Insurance Information

Primary Care Physician

Financial Agreement and Policies

Permission for "Remind" App

Photo and Video Consent

Additional Consent

Health and Wellness Policy

Office Hours of Operation and Closure Policy

HIPPA Notices

Consent for Purposes of Treatment, Payment, and Healthcare Operations