Patient Agreement Forms  Logo
  • Patient Insurance/Payment Agreement

  • Claims Submission: If going through an insurance company that we are in-network with, we will work to provide you with an estimate of benefits prior to starting services.  Please be aware that a quote of eligibility and benefits is not a guarantee of payment from the insurance company. We will submit the insurance claims for rendered services for you following the session. Your insurance company may need you to supply certain information directly. It is your ultimate responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not a party to that contract. 

    Termination of Insurance: In the event your insurance is terminated for any reason and we are not able to collect payment from your insurance provider, you will be responsible for payment in full for said unpaid claims. 

    Coverage Changes: If your insurance changes, please notify us before your next visit so that we can make the appropriate changes to help you receive your maximum benefits. In the event you do not notify our office in a timely manner and your insurance has expired, becomes inactive, or the new plan require a referral or prior authorization that is not yet in place, you will be responsible for any unpaid claims. 

    Nonpayment: If your account is over 90 days past due, you will receive a letter stating that you have 30 days to pay your account in full. Partial payments will not be accepted unless arrangements are made in advance with our office. Please be aware that if your balance remains unpaid, we may refer your account to a collection agency and your child may be discharged from our practice.

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  • Patient Cancellation and Attendance Policy Agreement

  • Central Texas Therapy Spot, PLLC requires 24 hours notice in the event of a cancellation.  If you need to cancel or reschedule an appointment please contact your therapist directly, or call our office to notify us as soon as possible.

    There is a $50.00 charge for a cancellation without proper notice. This charge also applies to a no-show and cancellations made without proper notice. The charge will not be covered by insurance, but is your responsibility. The staff may exercise discretion in certain circumstances on a first "no- show" or improper cancellation. 

    Central Texas Therapy Spot also has a monthly 80% attendance policy. Patients should attend at least 80% of scheduled sessions. Patients who drop below 80% attendance secondary to patient cancellations are subject to dismissal.

    When you don’t show as scheduled, three people are hurt: 

    1. The patient because they don't get the treatment needed.  If they aren’t here we can’t help your child to reach desired goals. 
    2. The therapist who now has a space in their schedule since the time was reserved for your child personally.
    3. Another patient who could have been scheduled for treatment if there had been proper notice. 

    I have read and/or had the above policy explained to me. I understand and will abide by the policy above.

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