Speech Therapy Patient Rights and Responsibilities Agreement

Patient Rights

As a patient receiving speech therapy services, you have the right to:

1. Respectful Treatment

   • Be treated with dignity and respect
   • Receive care without discrimination
   • Have your cultural and personal values respected

2. Quality Care

   • Receive high-quality speech therapy services
   • Have your treatment explained in terms you can understand
   • Know the names and qualifications of your care providers

3. Information and Choice

   • Participate in developing your treatment plan
   • Refuse treatment after understanding the consequences
   • Access your medical records
   • Receive detailed information about fees and payment policies

4. Privacy

   • Have your personal health information protected
   • Receive treatment in a confidential setting
   • Review your records with your therapist

Patient Responsibilities

As a patient, you are responsible for:

1. Active Participation

   • Attending scheduled appointments
   • Participating actively in therapy sessions
   • Completing recommended home exercises

2. Communication

   • Providing accurate medical history
   • Informing staff of changes in your condition
   • Asking questions when you don't understand

3. Administrative Matters

   • Providing current insurance information
   • Making timely payments for services
   • Giving 24-hour notice for cancellations

4. Conduct

   • Following facility rules and regulations
   • Being respectful to staff and other patients
   • Maintaining personal hygiene

Acknowledgment

I have read and understand my rights and responsibilities as a speech therapy patient.

Patient Name: _____________________

Signature: ________________________

Date: ____________________________

SLP Signature: ____________________