I acknowledge I am fully responsible for all speech therapy charges. Parker Speech and Language Therapy will submit claims to my insurance company on my behalf and I will be responsible for paying copays or session charges each session. I will not hold Parker Speech and Language Therapy responsible for any incurred charges. Payment is due at the time of service and no balances, including copays, shall be carried past 30 days without penalty of services being discontinued or placed on hold. In the event of default of payment or if my account is placed with an attorney or collection agency for collection of balance, I agree to pay attorney’s fees and court costs if applicable.
I authorize Parker Speech and Language Therapy to provide physician- prescribed treatment for the patient and I understand that no guarantee or assurance has been made regarding potential or results that may be obtained regardless of the cost incurred for treatment.
In the event my insurance excludes speech therapy services, I agree to enter into contract with Parker Speech and Language Therapy for a cash-rate fee which will be paid at the time of services. Accounts past due by 60 days will be charged $25.00, then $25.00 for every month thereafter until the balance is paid in full. I understand all NSF checks are subject to a $25.00 fee.