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September 29, 2025pcsoklahomaUncategorized

Pediatric Communication Solutions, Inc. (PCS) is committed to providing a safe, supportive, and welcoming environment for all of our children, parents, students, and staff. To ensure safety and comfort for all we expect all individuals to act in a mature and responsible way that respects the rights and dignity of others. This applies to all staff, students, parents, family members, and guests who enter our facilities.

CODE OF CONDUCT
Pediatric Communication Solutions, Inc. is committed to providing a safe, supportive, and welcoming environment for all of our children, parents, students, and staff. To ensure safety and comfort for all, we expect all individuals to act in a mature and responsible way that respects the rights and dignity of others. This applies to all staff, students, parents, family members, and guests who enter our facilities. Our code of conduct does not permit language or action that intimidates, hurts, or frightens another person, or that falls below a generally accepted standard of conduct.

DISCIPLINE POLICY
Cooperation and a positive attitude of all clients is a vital component of speech language services; therefore, any violent behavior will not be tolerated. Pediatric Communication Solutions, Inc. reserves the right to determine who is or is not suitable for speech-language services and will take all measures to provide a safe and conducive environment for learning. We support a three strikes behavior policy; however, we reserve the right to a zero-tolerance policy regarding violence. In the case of violent behavior by a child, services will be immediately terminated.
• First offense is a verbal warning.
• Second offense is a written warning signed by the parent and owner.
• Third offense will be a consultation with the owner and a possible suspension or termination of services.
• Your child can and will participate fully in speech-language services and will cooperate and accept our guidance in standards of behavior. Failure to adhere to these standards may result in suspension or termination of services.
• We aim to provide a positive learning environment for all children, and we welcome communication with parents anytime.

COMMUNICATION AGREEMENT
I consent to Pediatric Communication Solutions, Inc. (PCS) staff and its affiliates using any telephone numbers (including cell phone/wireless numbers), email addresses, and other electronic communications I provide to PCS for appointment, referral, treatment, billing, debt collection, and other purposes related to my/my child’s care. This includes phone calls, voice messages, text messages, emails, and other electronic communications. If I discontinue use of any phone number provided, I shall promptly notify PCS and will hold PCS and its affiliates harmless from any expenses or other loss arising from any failure to notify. I understand that standard text messages, unencrypted emails, and other electronic communications that I send and receive from PCS may flow through networks that are not secure and may be at risk of exposure of my health information (for example, the message could be intercepted and viewed by an unauthorized third party). In addition, once the text, email, or other electronic communication is received by me, someone may be able to access my phone, applications, digital devices, or email accounts and read the message. I understand that it is my responsibility to make sure that only authorized people are allowed to access my email, phone messages, cell phone, and digital devices. I understand these risks and give permission to PCS to communicate with me via wireless/cell phone, text message, unencrypted email, and other electronic communications.

NON-DISCRIMMINATION
It is the policy of Pediatric Communication Solutions, Inc. to maintain an environment free of all forms of discrimination and rules for acceptance and participation in speech services are the same for everyone regardless of race, color, ethnicity, religion, or gender.

TERMINATION / DISMISSAL POLICY
Dismissal/termination of speech and/or language services either permanently or for some specified time period, are set forth in accordance with the American Speech-Language Hearing Association Code of Ethics. The factors for dismissal/ termination taken into account include: 1. Individuals shall evaluate the effectiveness of services rendered and of products dispensed and shall provide services or dispense products only when benefit can reasonably be expected. 2. Individuals shall not guarantee the results of any treatment or procedure, directly or by implication; however, they may make a reasonable statement of prognosis. Further, Pediatric Communication Solutions, Inc. has the right to terminate services at any time.

Termination and /or dismissal may occur due to:
1. The communication disorder has been remediated or compensatory strategies have been successfully established;
2. The individual or family chooses not to participate in treatment, relocates, or seeks another provider;
3. Treatment no longer results in measurable benefits after multiple modifications have been attempted.
4. Attendance has not been adequate to effectively remediate the communication disorder
5. Multiple policies and/or procedures have been violated and terms of agreement between Pediatric Communication Solutions, Inc. and patients have not been successful.
6. Non-compliance with treatment recommendations.
7. Failure or refusal to pay for services.

It is strongly encouraged that clients speak with the clinician to express any concerns with treatment so that we may resolve any possible conflicts. In accordance with the ASHA code of ethics, if treatment is no longer efficacious, it will be terminated. Pediatric Communication Solutions, Inc. will honor requests to transition services and/or make referrals or recommendations for future clinicians. Please contact our offices during business hours to make arrangements if financial situations arise.

REFUND POLICY
No refunds will be made for services (evaluations or treatment) already rendered. If at any time, it is determined that a refund should be appropriate for a pre-payment of services that are no longer going to be utilized, the client should speak with the owner to make arrangements.

SCHEDULING
Patients will be required to sign up for recurring/standing appointments weekly/monthly. Reschedules are allowed and are detailed within our attendance policy (below). All schedule changes must be made through the speech-language pathologist directly either via phone, email, or text.

ATTENDANCE / CANCELLATION POLICY
Regular attendance of scheduled therapy sessions is crucial to your child’s progress. Therefore, to better serve our growing number of patients and their families, we require everyone to follow our 85% attendance policy and respect our “24-hour cancellation” policy regarding appointment cancellations and rescheduling. Failure to cancel or re-schedule the appointment within 24 hours of the scheduled appointment will result in a fee for a missed appointment. The missed appointment / cancellation / no-show fee is $35 per therapy session and $100 for evaluations.

Our attendance policy is as follows: All clients must maintain 85% attendance for all therapy appointments. Three no shows for scheduled appointments results in immediate discharge. Pediatric Communication Solutions, Inc. reserves the right to discharge patients who do not maintain 85% attendance or violate the “no show/no call” policy. Pediatric Communication Solutions, Inc. understands that unexpected circumstances can never fully be avoided, and we are more than willing to work with each of you on a case by case basis to resolve any unexpected scheduling issues that may arise occasionally. Please make sure you notify your child’s speech-language pathologist when you are unable to keep scheduled appointments. If you have any questions or need to reschedule an appointment, please do not hesitate to call the clinic at 405-438-0090. We will be more than happy to work with you.

In order for your child to continue making progress, our therapists and front office staff can work together with you to reschedule any cancelled/missed appointments. This may mean that another therapist may see your child depending on the rescheduled time and availability. Cancellations may be made through the your child’s speech-language pathologist or the Pediatric Communication Solutions office via phone, email, or text with 24 hours advance notice whenever possible. We understand that kids get sick, and emergencies happen. So, if 24 hours’ notice is not possible, please call as soon as you can, because we often have clients waiting to be seen who could use your child’s cancelled appointment spot. Voicemail is available for you to leave a message 24 hours a day, 7 days a week. 1 cancellation per month is allowed, as long as it is rescheduled within the following week (upon availability). We strive to provide 30 minutes of productive treatment each session.

SICK / ILLNESS POLICY
It is the policy of Pediatric Communication Solutions, Inc. that in the event the patient becomes ill, the following guidelines will be utilized for re-admitting patients into treatments as listed below:

Cancel appointment if one or more of these conditions are present:
• Fever of 100 degrees or above
• Vomiting, nausea or severe abdominal pain
• Other symptoms suggestive of acute illness

Return to Therapy Guidelines:
• Fever free for full 24 hours without medication
• Symptom free of vomiting, nausea or severe abdominal pain
• All health conditions listed above have been treated and resolved

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    NEW PATIENT INFORMATION PACKET

    "*" indicates required fields

    929 E. Britton Rd
    Oklahoma City, OK 73114
    4331 Adams Rd
    Suite 111
    Norman, OK 73069

    PATIENT INFORMATION

    Date of Birth*
    Gender*

    PARENT / LEGAL GUARDIAN INFORMATION

    Parent / Legal Guardian's Address*
    Parent / Legal Guardian*
    Parent / Legal Guardian
    Does the child live with both parents?

    INSURANCE INFORMATION

    We will need a copy of the insurance card in order to file a claim.
    Insurance or Self-Pay?*
    Policy Holder*
    Policy Holder's Date of Birth*
    I have a secondary insurance.
    Policy Holder
    Policy Holder's Date of Birth

    CASE HISTORY

    Did your child pass his/her newborn hearing screening?
    Has your child had a hearing screening or evaluation within the past year?
    Do you have any specific concerns regarding your child's hearing / ears?
    How does the child usually communicate? (check all that apply)
    Is the child’s speech difficult to understand?

    PRENATAL AND BIRTH HISTORY

    Is the child adopted?
    Is the child in foster care?
    Type of delivery?

    DEVELOPMENTAL HISTORY

    Please list the approximate AGE your child achieved these developmental communication milestones:
    babbled
    use of gestures
    first word
    2-word phrases
    simple sentences
     
    Please list the approximate AGE your child achieved these developmental motor milestones:
    sat alone
    crawled
    fed self
    walked
    toilet trained
     

    CURRENT SPEECH, LANGUAGE, & HEARING

    Does your child understand what you are saying?
    Does your child retrieve/point to common objects upon request?
    Does your child follow simple directions?
    Does your child respond correctly to yes/no questions?
    Does your child respond correctly to who/what/where/when/why questions?
    Does your child have difficulty producing speech sounds?
    Does your child frequently stutter when trying to speak?
    Does your child communicate with words more often than gestures or crying?
    Does your child speak in 2-4 word sentences?
    Does your child make eye contact with you/other people?
    Does your child become easily distracted?
    Check all behavioral characteristics that describe your child:

    MEDICAL HISTORY

    My child is allergic to (select all that apply):

    Child's general health is:

    EDUCATIONAL HISTORY

    Does your child have an:
    Does your child attend Daycare?
    Does your child attend a Mother’s Day Out program?

    ADDITIONAL INFORMATION

    PEDIATRIC COMMUNICATION SOLUTIONS, INC. POLICIES AND PROCEDURES

    INFORMED CONSENT*
    I HAVE READ, UNDERSTAND AND AGREE TO PEDIATRIC COMMUNICATION SOLUTIONS INC.’S POLICIES AND PROCEDURES.

    CREDIT CARD AUTHORIZATION FORM

    Pediatric Communication Solutions, Inc. is committed to making our billing process as simple and easy as possible, We require that all patients keep a valid credit card on file with our office. Payment is due at the time of service.
    Cardholder's Name*
    Enter the 3 digit code on the back of the card
    Is the billing address for the credit card entered the same as the home address entered above?*
    Billing Address
    Enter the billing address associated with the credit card entered.
    INFORMED CONSENT*
    As the legal guardian and guarantor on the account, I authorize Pediatric Communications Solutions, Inc. to charge my credit / debit card entered for charges associated with the evaluation, therapy sessions and no-show fees. I understand that my payment information will be securely saved in my file for future payments.
    INFORMED CONSENT*
    I consent to Pediatric Communication Solutions, Inc. (PCS) staff and its affiliates using any telephone numbers (including cell phone/wireless numbers), email addresses, and other electronic communications I provide to PCS for appointment, referral, treatment, billing, debt collection, and other purposes related to my/my child’s care. This includes phone calls, voice messages, text messages, emails, and other electronic communications. If I discontinue use of any phone number provided, I shall promptly notify PCS and will hold PCS and its affiliates harmless from any expenses or other loss arising from any failure to notify. I understand that standard text messages, unencrypted emails, and other electronic communications that I send and receive from PCS may flow through networks that are not secure and may be at risk of exposure of my health information (for example, the message could be intercepted and viewed by an unauthorized third party). In addition, once the text, email, or other electronic communication is received by me, someone may be able to access my phone, applications, digital devices, or email accounts and read the message. I understand that it is my responsibility to make sure that only authorized people are allowed to access my email, phone messages, cell phone, and digital devices. I understand these risks and give permission to PCS to communicate with me via wireless/cell phone, text message, unencrypted email, and other electronic communications. I authorize PCS to utilize the following communication methods with me.
    APPROVED COMMUNICATION METHODS:*

    PATIENT LIABILITY FORM

    This form is to inform you that certain speech-language pathology services may not be covered under your commercial insurance policy due to plan exclusions or benefit limitations. While we will make every effort to verify and bill your insurance appropriately, coverage is ultimately determined by your insurance provider.
    THIS INSURANCE AGREEMENT (THE “AGREEMENT”) IS MADE AND ENTERED INTO BETWEEN (“LEGAL GUARDIAN”) AND PEDIATRIC COMMUNICATION SOLUTIONS, INC.*
    ACKNOWLEDGMENT*
    I have read and understand the above statements. I acknowledge that I am financially responsible for any speech-language pathology services not covered by my insurance provider.
    PARENT / LEGAL GUARDIAN'S NAME*
    TODAY'S DATE*

    Call: (405) 438-0090

    Fax: (405) 493-0717

    office@pcs-ok.com

    You’ve found your home for pediatric speech therapy in OKC – and we’re glad you’re here! Learn about our supportive, relaxed and friendly environment focused on connecting with you to ensure the best outcomes possible for your child.

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