Payment and Attendance Policy:
Please Read This Carefully
I understand that I will be charged a LATE CANCELLATION fee of $25 if I fail to give at least 24- hour notice prior to canceling my appointment. If a make-up session is scheduled within the same week, this fee will not apply.
I understand that I will be charged a LATE CANCELLATION fee of $35 if I cancel within 4 hours of my appointment time.
I understand that I will be charged a NO-SHOW fee of $50 if I fail to show for my appointment.
I understand that I am responsible for knowing my co-payment amount and deductible amount.
I understand that if insurance information is not available or you do not have insurance, payment is due in full unless other arrangements have been approved by the administration.
As a courtesy to our clients, we will verify and file your insurance; however, this is not a guarantee of coverage or payment. We strongly suggest that you read your policy manual as it pertains to therapy coverage. Many insurance companies have stipulations, such as usually & customary fees (UCR), limited therapy sessions, limited reimbursable amounts per session, deductibles, co-payments, supplies, etc. Such stipulations should be indicated in your policy manual. YOU ARE RESPONSIBLE FOR AMOUNTS NOT COVERED by your insurance.
I understand that my child’s weekly appointment time will not be guaranteed if payments are not received for services within 7 days of the date of service. This applies to children seen at the clinic and at school.
I understand that Therapeutic Learning Center has the right to discharge my child if payment for service is not received timely. Payment for services is expected following each session or at the time of service.
I understand that if payments are received past 30 days from the date of service, a $10 late fee will apply. If payments are received 45 days or more from the date of service, a $20 fee will apply. Any balance 60 days or more will be turned over to an outside collections service.
If collections services or an attorney is employed to collect payments due, I will also be responsible for interest and expenses, including but not limited to costs and attorneys’ fees.
I understand that I will be charged a $20 out of office fee if my child is seen outside of the therapy clinic such as school or daycare.
I understand that it is my responsibility to notify my child’s therapist if my child is not at school or daycare when the therapist is scheduled to see your child. A no-show fee will be charged if your child is not at school or daycare and the therapist was not notified.
I understand that I will provide the office with a credit card to keep on file for payment when my child is seen outside of the therapy clinic such as school or daycare.
Signing below indicates you understand and agree to the terms of this policy.