We cannot initiate therapeutic services until signed authorization is provided.
I understand and agree that I am personally responsible for charges incurred for services rendered by the office of Creative Speech Solutions, LLC if any of the following apply:
1. My health plan/school district does not cover 100% of the services rendered for any reason.
2. I do not provide the office of Creative Speech Solutions, LLC with the correct insurance information.
3. I have chosen not to use my medical coverage at the time services are rendered.
4. I have a health plan that considers this office to be out of network or not otherwise a covered provider of service.
5. I have not obtained a referral, preauthorization or other required authorization.
6. My benefit parameters limit or exclude coverage for therapy services.
7. My coverage changes during the course of therapy and/or no longer covers/limits or excludes therapy services.
8. I exceed my benefit limitations.
I understand and agree that in-network or out-of-network claims not paid by my insurer/school district after 60-days become the responsibility of the guarantor/subscriber.
I further understand and agree that if I appeal my insurance company’s decision regarding coverage, I will pay for services (past and present) until the appeal process is complete.
I understand and agree that if Creative Speech Solutions, LLC submits my claim(s) for services as an in-network provider, bills for services rendered but not allowed, covered or reimbursed to Creative Speech Solutions, LLC by my insurer are due upon receipt of said bill. All other bills for services rendered are also due upon receipt, including but not limited to bills for co-pays, deductible amounts, and therapy. I also understand and agree to pay interest at a yearly rate of 12% on any remaining balance not paid within 60 days from the date of any bill. I understand and agree to pay any collection fees or costs, attorney’s fees, and/or related costs and expenses incurred in pursuing any balance not paid within 90 days from the date of the bill.
I understand and agree that all outstanding balances that I have not paid within 60 days will be charged to the credit card I have on file with Creative Speech Solutions, LLC.
I also understand that Creative Speech Solutions, LLC is only in network with Aetna and Cigna for Speech and Language Therapy, Feeding Therapy, and AAC and is not in network with any insurance carriers for Occupational Therapy.
I have read and understand the policies and procedures set forth by Creative Speech Solutions, LLC which are listed on our website and this Patient Liability Statement. By signing below, I hereby agree to the terms, conditions, and provisions therein, and authorize Creative Speech Solutions, LLC to provide services to my child.