I have Blue Cross/Blue Shield insurance and authorize AGB Speech Therapy to bill my coverage provider for services.
Clients must obtain a referral from the Primary Care Manager (PCM) even if their policy states a referral is not necessary.
Clients who have not met deductibles must be prepared to pay any costs out of pocket.
If insurance coverage is denied for any reason, clients must be prepared to pay privately for therapy services at the current payout rate.
Co-pays and other fees not covered by insurance will be billed via emailed invoice at the end of each month. Payment is due immediately upon receipt of invoice, unless otherwise stated.
After 10 business days, a late fee of $10 per day will be applied to the invoice.
By clicking "Next," I am agreeing to payment policy.
My signature at the end of this form indicates that I give permission for AGB Speech Therapy to submit claims and authorize release of medical or other insurance information in order to bill my insurance on my behalf.