2026 Financial Policy

Name of Patient:

First NameLast Name

Name Parent/Guardian/Responsible Party:

First NameLast Name

Email

example@example.com

Thank you for choosing Greater Atlanta Speech and Language Clinics, Inc. (GASLC, Inc.) for your child’s speech, occupational, and/or physical therapy. We are committed to providing high-quality, family-centered care and want your experience with us to be successful. Please review and sign the following Financial Policy, as payment responsibilities are considered a part of treatment.

GASLC, Inc. considers the adult who signs this form as the Parent or Responsible Party. This individual is the financial guarantor for the patient’s account in all circumstances and without exception.

We strive to provide the best possible treatment for every patient and charge fees that are usual and customary for our area.

Accepted Payment Methods include: cash, checks, and most major credit cards.
Copayments and coinsurance amounts are due at each visit. You may be asked to leave a credit card on file.

We are considered in-network for the following insurance companies: Cigna, United Healthcare, Blue Cross/Blue Shield, Aetna, Ambetter, and Tricare East. We also accept Deeming Waiver, PeachState, Amerigroup, Caresource, and Medicaid for children up through age 21.

While we are in-network with many carriers, in-network status does not guarantee coverage or payment. Some (or all) services provided may be considered non-covered by your specific plan.

Your insurance policy is a contract between you and your insurance company. GASLC, Inc. is not a party to that contract, and you remain responsible for any portion of services not covered by your plan.

All insurance claims for services provided at Greater Atlanta Speech and Language Clinics (GASLC) are submitted as a courtesy to our families and are subject to review by your insurance carrier. GASLC will submit each claim to your insurance company up to two (2) times per appointment. After two submissions, any additional appeals or follow-up are the responsibility of the Parent or Responsible Party, unless a secondary source of payment has been established. This includes, but is not limited to:insurance denials of coverage, unmet deductibles, policy maximums, annual or lifetime benefit limits being exceeded, or a lack of payment from your insurance carrier within a reasonable timeframe, even if you are actively appealing the claim with your insurance company. The Parent or Responsible Party remains financially responsible for all charges not paid by insurance.

I Understand

Client/Parent Initials*

If your insurance company denies coverage for any reason, you are responsible for payment of all charges, and the full account balance is due on the first day of each month.Please be aware that when claims are filed with private insurance companies, it may take 30–60 days or longer for us to receive an Explanation of Benefits (EOB). Because of this delay, by the time we receive notification of whether a claim has been paid or denied, you may have accumulated more than one month of invoices.We encourage families to plan accordingly, as all outstanding balances must be paid in full by the first of the following month, regardless of delays in insurance processing..*

I understand

Client/Parent Initials*

Please note that a request for preauthorization does NOT guarantee approval and coverage is not retroactive. If you prefer to begin services before preauthorization is obtained, you are welcome to do so on a private-pay basis. All private-pay fees must be paid at the time services are rendered. If preauthorization is later approved by your insurance carrier, previous private-pay charges cannot be submitted retroactively and will not be reimbursed by insurance.*

I understand

Client/Parent Initials*

You are responsible for tracking the number of therapy visits covered by your insurance plan each calendar year. If the number of visits provided by GASLC exceeds the maximum allowed by your insurance carrier, you will be responsible for payment in full for any additional services rendered.*

I understand

Client/Parent Initials*

A request for preauthorization does NOT guarantee approval if you have already reached or exceeded the number of visits allowed by your insurance plan. If you choose to continue services beyond your approved visit limit and your insurance company does not issue payment, you are financially responsible for all charges at the contracted rate.*

I understand

Client/Parent Initials*

Most insurance companies require a re-evaluation once per year to continue therapy services. Please note that the charges for an annual re-evaluation may differ from the cost of your regular therapy sessions. By providing your initials, you acknowledge that you understand and agree you will be responsible for any copay, coinsurance, or deductible amounts not covered or paid by your insurance company for the yearly re-evaluation.*

I understand

Client/Parent Initials*

GASLC, Inc. will exercise the right to charge 10% interest on past due accounts. This will accrue each 30 days the account is overdue. Additionally, there may be a $10 late processing fee per month.*

I understand

Client/Parent Initials*

Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns.*

I have read the above Financial Policy and understand and agree to abide by this policy.

Signature

Date*