Consent to Treat Speech Language Pathology Services and Medicare Billing Authorization

Cognify Health Speech Pathology, Professional Corporation

Permission for care

I consent to evaluation and treatment by the licensed speech-language pathologists of Cognify Health Speech Pathology, Professional Corporation (Cognify Health). Services may address speech, language, voice, cognitive communication, and swallowing, as appropriate to my needs and the agreed plan of care. Care may include education, practice activities, caregiver training with my permission, and coordination with my treating health professionals as permitted by law.

Understanding my care

My clinician will explain the proposed services, expected benefits, material risks, and reasonable alternatives, including no treatment. Depending on the activity, I may experience fatigue, frustration, or discomfort. Swallowing activities may involve choking or aspiration risk; my clinician will explain any relevant precautions before proceeding. Results are not guaranteed.

I may ask questions, request communication assistance, decline an activity, or stop treatment at any time. I will tell my clinician about discomfort, changes in my health, and any limits on my consent. This general consent does not replace a discussion or any separate consent needed for a specific procedure or telehealth service.

My agreement

I have read this form, or it has been explained to me in a way I understand. I have had the opportunity to ask questions and received answers I understand. I voluntarily consent to the care described above. I may withdraw consent by telling Cognify Health. If I sign as a representative, I confirm that I have authority to make this treatment decision for the patient.

Claim submission and information release for Item 12

I request Medicare payment for services furnished to me by Cognify Health Speech Pathology, Professional Corporation (Cognify Health). I authorize Cognify Health to submit claims and release to Medicare and its claims processors the medical information needed to process those claims.

Payment authorization for Item 13

I authorize payment of Medicare benefits directly to Cognify Health for its services when assignment is accepted or direct payment is required by Medicare. This authorization does not guarantee coverage or payment.

Signature on file and duration

Cognify Health may retain this signed authorization and use “Signature on File” for CMS-1500 Items 12 and 13, and the corresponding electronic claim indicators when applicable. It applies to continuing services until I or my authorized representative revoke it by notifying Cognify Health. Revocation does not undo actions already taken in reliance on this authorization.

This form is not an Advance Beneficiary Notice of Noncoverage (ABN) and does not waive my Medicare rights or make me responsible for every denied claim. Any patient charges remain subject to Medicare rules. It is not permission for unrelated disclosure of my records.