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!*10810 Darnestown Road (suite 102), N. Potomac, MD 20878 *727 Lake Varuna Drive, Gaithersburg, MD 20878 * Phone/Fax: (240) 200-5035Anat Sohn, M.A., CCC-SLPMetro Speech Therapy, LLCPediatric and Adult Speech-Language PathologistMD License Number: 05839Dear ,This packet contains forms to be completed and returned by mail or fax prior to your appointment. Please return allforms by mail or fax one week prior to the evaluation or treatment date. If you fax the forms, please bring theoriginals on the date of the appointment. If you have additional information, such as school or therapy reports, pleaseforward those as well. Should you have questions about the completion of these forms, please call (240) 200-5305.Please return forms to:Anat Sohn, M.A., CCC-SLPMetro Speech Therapy, LLC10810 Darnestown Road, N. Potomac, MD 20878Fax #: (240) 200-5305Sincerely,Anat Sohn, M.A., CCC-SLPPlease make sure to complete the following items to help prepare for the evaluation or initiation of treatment. Complete the packet. Send or fax the completed packet. If the packet is faxed please bring original forms to evaluation/treatment date. Send other relevant reports.

!*10810 Darnestown Road (suite 102), N. Potomac, MD 20878*727 Lake Varuna Drive, Gaithersburg, MD 20878 * Phone/Fax: (240) 200-5035Anat Sohn, M.A., CCC-SLPMetro Speech Therapy, LLCPediatric and Adult Speech-Language PathologistMD License Number: 05839Payment for ServicesFor your convenience, we accept cash, checks, credit cards and debit cards. Payments will be made at thetime of service and a receipt will be sent to you via email.Please sign and return the Credit Card/ Debit Transaction Form along with the remainder of the forms. Allcorrespondences regarding billing should be mailed to this address:Anat Sohn, M.A., CCC-SLPMetro Speech Therapy, LLC10810 Darnestown Road, N. Potomac, MD 20878Fax #: (240) 200-5305Cancellation and No-Show PolicyCancellations with less than 24 hours from your scheduled appointment will be billed 30. For all cancellations, please call (240) 200-5305.We greatly appreciate as much advanced notice as possible of vacations or other eventsfor which you are unable to keep your appointment.Appointments that are not cancelled are considered “no-shows”. These appointmentswill be billed at the full rate and the client will be responsible for full payment.

!*10810 Darnestown Road (suite 102), N. Potomac, MD 20878*727 Lake Varuna Drive, Gaithersburg, MD 20878 * Phone/Fax: (240) 200-5035Anat Sohn, M.A., CCC-SLPMetro Speech Therapy, LLCPediatric and Adult Speech-Language PathologistMD License Number: 05839Credit Card/ Debit Transaction Processing Authorization FormYes, I would like you to automatically charge my credit card for services rendered.CARD TYPENUMBEREXP. DATE3 DIGIT CODE ON BACKVisaBilling Address and Name on the card:CARD TYPENUMBEREXP. DATE3 DIGIT CODE ON BACKMasterCardBilling address and Name on the card:CARD TYPENUMBEREXP. DATEAmerican Express4 DIGIT CODE ON FRONTBilling address and Name on the card:

Page 2 (Credit Card/ Debit Transaction Processing Authorization Form)By signing this Agreement, and marking the box noted above, the undersigned does hereby agree as follows: (i) theundersigned does hereby authorize and agree that Anat Sohn, M.A., CCC-SLP and/or its duly authorized agent (MetroSpeech Therapy, LLC) has the right to charge to the above identified credit card and/or debit the account identifiedabove any and all amounts that are owed to the Company and/or its consultants, (ii) the undersigned agrees that itssignature on this Agreement shall be deemed its signature on any sales charge receipt or other form and if anymerchant services, credit card company, or bank requests to view the undersigned signature on a sales charge receiptor other form, the Company may provide such company with a copy of this Agreement and such shall be deemedconclusive proof that the undersigned approved and authorized the charge and/or debit at issue, and the undersigneddoes hereby waive any right to dispute its authorization to such charge based on an invalid or non-existent signature.The undersigned understands and agrees that the above payment option and charges or debits will continue eachmonth for services rendered by the Company and/or its consultants until such time as the undersigned has providedwritten notice to the Company to stop such automatic charges and/or debits. The undersigned shall be fullyresponsible for ensuring that it has sufficient credit and/or funds to cover the charges or debits, and shall indemnifythe Company against all costs incurred as a result of any declined charge or debit.AGREED AND ACCEPTEDCardholder’s Signature:Print Name:*All credit and debit cards will be processed at the time of service.Date:I, authorize Anat Sohn, M.A.,CCC-SLP to send paid invoices viaelectronic mail to (email address).Signature:Date:

!*10810 Darnestown Road (suite 102), N. Potomac, MD 20878*727 Lake Varuna Drive, Gaithersburg, MD 20878 * Phone/Fax: (240) 200-5035Anat Sohn, M.A., CCC-SLPMetro Speech Therapy, LLCPediatric and Adult Speech-Language PathologistMD License Number: 05839I, (print name), acknowledge and accept full andcomplete responsibility for payment of all services rendered by Metro Speech Therapy, Anat Sohn, M.A.,CCC- SLP, and/or its consultants. I acknowledge that I have received written explanation of the cancellationpolicy and payment policy and I agree to both.I understand that health insurance policies are an arrangement between my insurance company and myself,that all services rendered are charged directly to me, and that I am personally responsible for payment. Iunderstand that agreements regarding fee schedules, charges for cancelled appointments and late paymentfees are between Metro Speech Therapy, LLC and myself and are not related to potential insurancecoverage. I understand that Anat Sohn, M.A., CCC-SLP may assist me in completing forms to aid incollecting insurance benefits for services that are billable, but ultimately it is my responsibility to completeand file such forms. I agree to the release by Metro Speech Therapy, LLC and/or its duly authorized agentsof any information that is requested by my insurance company.DateSignature of client /(parent or legal guardian)Print Name

!*10810 Darnestown Road (suite 102), N. Potomac, MD 20878*727 Lake Varuna Drive, Gaithersburg, MD 20878 * Phone/Fax: (240) 200-5035Anat Sohn, M.A., CCC-SLPMetro Speech Therapy, LLCPediatric and Adult Speech-Language PathologistMD License Number: 05839Agreement to Terms of Payment (insurance)I, (print name), acknowledge and accept full andcomplete responsibility for payment of all services rendered by Metro Speech Therapy, Anat Sohn, M.A.,CCC- SLP, and/or its consultants that are not covered by my health insurance plan. I acknowledge that Ihave received written explanation of the cancellation policy, and payment policy and I am in agreement.I understand that I am responsible for my copay at the time services are rendered and Metro SpeechTherapy, LLC will submit claims to my health insurance company on my behalf. I understand that allpayments on claims that are denied by my health insurance company are my responsibility and that allservices rendered that are not covered by my health insurance company are charged directly to me. Iunderstand that agreements regarding fee schedules, charges for cancelled appointments and late paymentfees are between Metro Speech Therapy, LLC and myself and are not related to potential insurancecoverage. I understand that Anat Sohn, M.A., CCC-SLP will complete forms on my behalf in collectinginsurance benefits for services that are billable. I agree to the release by Metro Speech Therapy, LLC and/orits duly authorized agents of any information that is requested by my insurance company.DateSignature of client /(parent or legal guardian)Print Name

!*10810 Darnestown Road (suite 102), N. Potomac, MD 20878*727 Lake Varuna Drive, Gaithersburg, MD 20878 * Phone/Fax: (240) 200-5035Anat Sohn, M.A., CCC-SLPMetro Speech Therapy, LLCPediatric and Adult Speech-Language PathologistMD License Number: 05839INSURANCE INFORMATIONName of Primary Insurance Company:Insurance Company Phone# (Provider line):ID #: Group #:Card Holder”s name: Card Holder’s DOB:Name of Secondary Insurance Company:Insurance Company Phone# (provider line):ID #: Group #:Card Holder”s name: Card Holder’s DOB:

!*10810 Darnestown Road (suite 102), N. Potomac, MD 20878*727 Lake Varuna Drive, Gaithersburg, MD 20878 * Phone/Fax: (240) 200-5035Anat Sohn, M.A., CCC-SLPMetro Speech Therapy, LLCPediatric and Adult Speech-Language PathologistMD License Number: 05839Acknowledgement and Assumption of Risk (adult)I, (print name) acknowledge and agree to receivespeech therapy services from Anat Sohn, M.A., CCC-SLP and/or any independent contractor under theforegoing at Metro Speech Therapy, LLC. I acknowledge that there is some risk inherent in the use of thetherapy equipment and I agree to assume such risk and indemnify and hold Anat Sohn, M.A., CCC-SLP, anyof their independent contractors, and Metro Speech Therapy, LLC harmless from any and all losses andclaims for any injuries or other damages occurring to my belongings or myself.

!*10810 Darnestown Road (suite 102), N. Potomac, MD 20878*727 Lake Varuna Drive, Gaithersburg, MD 20878 * Phone/Fax: (240) 200-5035Anat Sohn, M.A., CCC-SLPMetro Speech Therapy, LLCPediatric and Adult Speech-Language PathologistMD License Number: 05839INTAKE FORM (ADULT)Name:Date of Birth:Address:Phone#: Home: Cell: Work:Email Address:Please describe your concerns and primary referral reasons: (Please include any medications orallergies/special diets:Briefly describe pertinent medical history such as any surgeries, medical diagnoses or any history ofseizures (or attach reports that will summarize the information.):Describe current health status:

Page 2 (INTAKE FORM-ADULT)Please briefly describe any therapeutic history you have had:

!*10810 Darnestown Road (suite 102), N. Potomac, MD 20878*727 Lake Varuna Drive, Gaithersburg, MD 20878 * Phone/Fax: (240) 200-5035Anat Sohn, M.A., CCC-SLPMetro Speech Therapy, LLCPediatric and Adult Speech-Language PathologistMD License Number: 05839Consent to Release Form (adult)I, (print name) give my permission and consent to Metro SpeechTherapy, Anat Sohn, M.A., CCC-SLP, and their respective consultants and agents (hereinafter, collectively, the“Company”) to discuss and speak with nurses, psychiatrists, medical doctors, other therapists, insurancerepresentatives, and other professionals (collectively, “Third Party Professionals”) regarding myself as such may beneeded in connection with the treatment and/or evaluation of myself by the Company.In addition, the Company is authorized to receive any records, files, charts, and other documentation and informationfrom such Third Party Professionals, and by signing this document, the undersigned is authorizing the release of anysuch information that may be held by a Third Party Professional to the Company. Any person who is provided a copyof this document may rely on it as the undersigned’s full and unconditional consent to the release of any and allinformation pertaining to the client/patient. The undersigned further authorizes the Company to release any and allinformation pertaining to the treatment and/or evaluation of the client/patient to any Third Party Professional that mayin any way be involved in the treatment and/or evaluation of the client/patient.The undersigned understands that some or all of the information obtained and/or released under this document may beprotected under federal regulations including but not limited to HIPAA. By authorizing a release of information, as setforth above, the undersigned understands and agrees that they are agreeing to the release of such informationnotwithstanding the protections under HIPPA, provided, however, it is understood and agreed that the Company willmaintain the confidentiality of any information obtained and will not disclose the same except as needed in the courseof treating or evaluating the client/patient.The undersigned, for his/herself and his or her successors and assigns, does hereby hold the Company harmless fromany and all claims relating to the release of information as provided above, and do hereby waive and release any claimagainst the Company relating to the release of such information as provided above. 9AGREED AND ACCEPTED:SignaturePrint Name

!*10810 Darnestown Road (suite 102), N. Potomac, MD 20878*727 Lake Varuna Drive, Gaithersburg, MD 20878 * Phone/Fax: (240) 200-5035Anat Sohn, M.A., CCC-SLPMetro Speech Therapy, LLCPediatric and Adult Speech-Language PathologistMD License Number: 05839Consent Form (adults)NAMEPHONE #INITIAL &DATEI, give my permission to Anat Sohn, M.A., CCC-SLP at MetroSpeech Therapy, LLC and their consultants (hereinafter, collectively, the “Company”) to speak with theabove listed professionals regarding myself .Signature

!*10810 Darnestown Road (suite 102), N. Potomac, MD 20878*727 Lake Varuna Drive, Gaithersburg, MD 20878 * Phone/Fax: (240) 200-5035Anat Sohn, M.A., CCC-SLPMetro Speech Therapy, LLCPediatric and Adult Speech-Language PathologistMD License Number: 05839VIDEO RECORDING ACKNOWLEDGEMENT AND CONSENT FORM (adult)I, (print name), understand that Metro Speech Therapy,Anat Sohn, M.A., CCC-SLP, and their consultants (hereinafter, the “Company”) may use video recordingand related equipment for diagnostic and treatment planning purposes.I further consent to the use of the video by the Company for the purpose of training personnel in the healthcare and education fields. I understand that if the Company uses the video for training purposes, theCompany will inform us of this intention. I understand that the Company will protect the family’s identityand will disclose only those details about the patient/client’s condition and treatment process necessary fortraining purposes. Accordingly, by signing below, the undersigned does hereby release and waive any andall rights that the undersigned may have in the videos, and assigns such rights to the Company to be used inaccordance with the terms of this Consent Form.Print NameSignatureDate

!*10810 Darnestown Road (suite 102), N. Potomac, MD 20878*727 Lake Varuna Drive, Gaithersburg, MD 20878 * Phone/Fax: (240) 200-5035Anat Sohn, M.A., CCC-SLPMetro Speech Therapy, LLCPediatric and Adult Speech-Language PathologistMD License Number: 05839GENERAL ACKNOWLEDGMENT OF FORMS (adult)I do hereby acknowledge and agree that: (i) I have read all of the forms and documents provided to me inconnection with the treatment and evaluation of myself) by Metro Speech Therapy, Anat Sohn, M.A., CCCSLP, and/or their respective consultants; (ii) I understand the meaning and intent of such forms, and agree tothe provisions contained therein; (iii) I have been given the opportunity to ask questions concerning theforms and any questions that I have asked have been answered to my satisfaction, and (iv) I have signed allof the forms upon my on free volition and without any coercion from any third party.Print NameSignatureDate

!*10810 Darnestown Road (suite 102), N. Potomac, MD 20878*727 Lake Varuna Drive, Gaithersburg, MD 20878 * Phone/Fax: (240) 200-5035Anat Sohn, M.A., CCC-SLPMetro Speech Therapy, LLCPediatric and Adult Speech-Language PathologistMD License Number: 05839PROFESSIONAL CONTACT FORM (adult)Name: Date: DOB:Referred by:Occupational Therapist:Telephone:Address:Physical Therapist:Telephone:Address:Speech-Language Address:

Page 2- PROFESSIONAL CONTACT FORM (adult)Psychologist/Psychiatrist (circle ss:Other Professional:Telephone:Address:

of their independent contractors, and Metro Speech Therapy, LLC harmless from any and all losses and claims for any injuries or other damages occurring to my belongings or myself. *10810 Darnestown Road (suite 102), N. Potomac, MD 20878 *727 Lake Varuna Drive, Gaithersburg, MD 20878 * Phone/Fax: (240) 200-5035