FINANCIAL AGREEMENT

(Effective October 1, 2018)



Client Name:

Date of Birth:

 
 
 
Thank you for choosing {Company Name} as your therapy provider. Please understand that payment of your bills is considered part of your child’s care. The following is a statement of our financial policy. We require a signed agreement for each child before the first appointment or consultation. If you have any questions, please ask for clarification from the administration before signing. Please do not direct your questions regarding billing or financial agreement to your treating therapist.
 
FINANCIAL POLICIES

INVOICES AND PAYMENTS
 
  1. Invoices will be created for statement account balances due. Prompt payment of balance in full is expected within 30 days of statement. If payment is not received within 30 days of statement date, treatment of client will be suspended.

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  2. If your account is past 90 days due, it will be turned over to a collection agency. All collection cost and attorney fees are the parent/guardian’s responsibility. Ultimately, the parent/guardian is responsible for all charges incurred for services.

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  3. {Company Name} accepts credit/debit cards, checks, cash and FSA payments. There is a $40 fee for returned checks.
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  4. We require a valid credit card authorization on file and we will contact you for approval to charge any outstanding balance past 30 days due.
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  5. In situations of divorce, separation, court orders, etc., the party initiating treatment will be financially responsible for the account.
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MEDICAL RECORDS FEES


Fees associated with medical records requests are noted below. Please allow a minimum of 30 days for all medical records requests.
    Effective July 1, 2018
Search, Retrieval and Other Direct Administrative Costs Up to: $25.88
Certification Fee Up to Per Record: $9.70
  Per page for pages 1-20: $0.97
Copying Costs for Records in Paper Form Per page for pages 21-100: $0.83
  Per page for pages over 100: $0.66

 
INSURANCE COVERAGE
 
  1. I understand that as parent/guardian of above client, I am responsible for any and all charges incurred resulting from treatment provided by {Company Name}, such as, but not limited to, deductibles, co-payments, co-insurance, or any non-covered services.
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  2.  As a service to our clients, {Company Name} will file your claims with your insurance company. Insurance policies are contracts made between the client/guardian and the insurance company. We will attempt to verify client insurance benefits; however, this is not a guarantee of payment for therapy services.
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  3. If your insurance company denies payment for services billed, the balance due may be transferred to the parent/guardian’s responsibility for payment in full.
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  4. Parent/guardian is responsible for informing {Company Name} of any and all changes in insurance information including group number, identification number, phone numbers, addresses, etc. All charges incurred are the responsibility of the parent.
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  5. If your insurance becomes inactive for any reason and you do not notify {Company Name} to cease services immediately until the issue is resolved, any balance accrued during your inactive status is your responsibility. See Private Pay Client fees listed in the following section. All charges incurred are the responsibility of the parent.
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PRIVATE PAY CLIENTS
  
   1.  When private paying, client will be invoiced on a weekly basis and balance is due upon receipt. The fees for individual therapy and assessments are as follows:

 
                             Professional              General Service Description  Hourly Rate
Supervising BCBA Assessments and evaluations
Supervision of staff
Program development
Staff training
Reports
School consultation, Participation in a meeting
Parent training
$95.00
BCaBAs
Master Level Therapists
Assessments and evaluations
Direct therapy
Supervision of staff with a BCBA
Program development
Reports
$75.00

 
Registered Behavior Technicians (RBT) and Therapists Direct Therapy $65.00
Combined Supervisor and Therapist Direct supervision of therapist and client’s program to include training, with both supervisor and therapist present $130.00
Assessment
 
Initial assessment and treatment plan report
 
$800.00
 
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CENTER BASED SERVICES:
(Please initial below for clients that are participating in center based services. Home services clients put N/A.)
 
  1. All clients participating in center based services will be responsible for an initial registration fee of $100.00 to cover to individualized educational materials and supplies, payable at time of registration and intake.
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CANCELLATIONS LATE ARRIVALS AND LATE PICK UPS
 
  1. Therapy will be most beneficial to your child with consistent attendance. A 24-hour notice is required for cancellation of therapy sessions and evaluations. {Company Name} charges a $50.00 fee for any appointment that is not cancelled with proper 24-hour notice unless special circumstances apply. In the event of sudden illness or medical condition, consideration will be given. After three consecutive missed or cancelled appointments, or chronic absenteeism for any reason, your child may be subject to discharge from therapies and proper notification will provided to your insurance carrier if indicated.
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  2. If you arrive more than 15 minutes late for a session or evaluation without notification, we may not be able to treat your child and this will be considered a no-show and a $50.00 no show fee will apply.
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  3.  If you are more than 10 minutes late in picking your child up from our center, you will be charged $20.00 late pick up fee.
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  4. On occasion, your child’s therapist may have a conflict or illness and need to cancel or reschedule. A make-up session will be attempted with one of the therapists on staff.
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  5. If you need to change/cancel your child’s appointment, contact your therapist or supervising BCBA
ASSIGNMENT OF BENEFITS

I authorize {Company Name} to release any information including diagnosis, treatment plan, evaluation report/summaries, progress notes, and discharge summaries for any treatment rendered to my child during the periods of such care to third party providers.I also authorize my insurance company to directly pay {Company Name} insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on behalf of my dependent(s) that are not covered by my insurance carrier

PARENT/GUARDIAN SIGNATURE:

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