PATIENT LIABILITY STATEMENT

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1 PATIENT LIABILITY STATEMENT We will nt initiate therapeutic services until signed authrizatin is prvided. I understand that I am persnally respnsible fr charges incurred fr services rendered by the ffice f Creative Speech Slutins, LLC if any f the fllwing apply: 1. My health plan/schl district des nt cver 100% f the services rendered fr any reasn. 2. I d nt prvide the ffice f Creative Speech Slutins, LLC with the crrect insurance infrmatin. 3. I have chsen nt t use my medical cverage at the time services are rendered. 4. I have a health plan that cnsiders this ffice t be ut f netwrk r nt therwise a cvered prvider f service. 5. I have nt btained a referral, preauthrizatin r ther required authrizatin. 6. My benefit parameters limit r exclude cverage fr therapy services. 7. My cverage changes during the curse f therapy and/r n lnger r des nt cver and/r limits and/r excludes my therapy services. 8. I exceed my benefit limitatins. I understand and agree that in netwrk r ut f netwrk claims nt paid by my insurer/schl district after 90-days becme the respnsibility f the guarantr/subscriber. I further understand and agree that if I appeal my insurance cmpany s decisin regarding cverage, I will pay fr services (past and present) until the appeal prcess is cmplete. I understand and agree that if Creative Speech Slutins, LLC submits my claim(s) fr services as an in-netwrk prvider, bills fr services rendered but nt allwed, cvered r reimbursed t Creative Speech Slutins, LLC by my insurer are due upn receipt f said bill. All ther bills fr services rendered are als due upn receipt, including but nt limited t bills fr c-pays, deductible amunts and therapy. I als understand and agree t pay interest at a yearly rate f 12% n any remaining balance nt paid within 30 days frm the date f any bill. I understand and agree t pay any cllectin fees r csts, attrney s fees, and/r related csts and expenses incurred in pursuing any balance nt paid within 90 days frm the date f the bill. I understand and agree that all utstanding balances that I have nt paid within 30 days will be charged t the credit card I have n file with Creative Speech Slutins, LLC. I als understand that Creative Speech Slutins, LLC is nly in netwrk with Aetna and Cigna fr Speech Therapy and is nt in netwrk with any insurance carriers fr Occupatinal Therapy, Nutritinal Services, r Music Therapy. I have read and understand the welcme letter summarizing plicies and prcedures set frth by Creative Speech Slutins, LLC and this Patient Liability Statement. By signing belw, I hereby agree t the terms, cnditins and prvisins therein, and authrize Creative Speech Slutins, LLC t prvide services t my child. Print Patient s Name Signature f Respnsible Persn(s)

2 CREDIT CARD AUTHORIZATION FORM I authrize Creative Speech Slutins, LLC t charge my Credit Card frm (Visa r MC). Credit Card Number CVV# Expiratin : Credit Card Billing Address: City State Zip Cde I acknwledge and understand that the abve-referenced is fr services rendered n my behalf and at my request by Creative Speech Slutins, LLC. I acknwledge that, by prviding this service Creative Speech Slutins, LLC has met its bligatins fr these charges. In the event that I am mre than 60 days verdue in paying my utstanding bill, I give Creative Speech Slutins, LLC cnsent t charge this credit card. I acknwledge that this agreement may be cancelled with written ntice at any time. I am enclsing cpies f my credit card frnt and back. I agree t prvide updated credit card infrmatin if this card shuld expire r be cancelled. Patient s Name: Name f Cardhlder: Signature f Cardhlder: :

3 PATIENT INFORMATION SHEET DATE: CHILD S NAME: D.O.B: AGE: PARENTS/GUARDIANS: ADDRESS: ALTERNATE ADDRESS: HOME#: MOBILE#: OFFICE#: 1: 2: PEDIATRICIAN: OFFICE#: FAX#: INSURANCE INFORMATION INSURANCE CO: ID#: GROUP#: PHONE: POLICY HOLDER S NAME: POLICY HOLDER S DOB: POLICY HOLDER S SOCIAL SECURITY NUMBER PLEASE NOTE THAT CSS IS IN NETWORK WITH CIGNA AND AETNA FOR SPEECH THERAPY. ALL OCCUPATIONAL THERAPY SERVICES ARE OUT OF NETWORK. BOARD OF EDUCATION/SCHOOL DISTRICT: PHONE#: OTHER PERTINENT PHYSICIANS OR THERAPISTS (E.G., NEUROLOGIST, ENT, OT, PT, SLP, ORTHOPEDIST) Signature:

4 Patient: CONSENT FOR TREATMENT I hereby authrize Creative Speech Slutins, LLC, t assess and treat the abve-named client using apprpriate assessment and treatment prcedures. AUTHORIZATION TO RELEASE INFORMATION I further authrize Creative Speech Slutins, LLC, t release infrmatin acquired in the curse f evaluatin and/r treatment t apprpriate individuals/insurance cmpanies/facilities/schls in rder t crdinate services r receive reimbursement. This wuld include treatment reprts, prgress ntes, and general discussin f the child (e.g., behaviral management, therapy gals, etc.). Individuals wuld include the child s pediatrician, ther physicians (e.g. neurlgist), ther treating therapists (e.g., schl SLP, ccupatinal therapist, etc.), and ther specialists (e.g., psychlgist). If there are any individuals and/r facilities t whm yu d nt wish infrmatin t be released, please list them belw: CANCELLATION POLICY I have read the Welcme Letter, which utlines the cancellatin plicy. I understand that: 1. All cancellatins made with less than 24 hurs ntice, fr any reasn ther than the illness f the treated patient, will be charged a cancellatin fee ($50 fr 30 minutes, $60 fr 45 minutes and $75 fr ne hur sessins). 2. This fee cannt be billed t my insurance cmpany. Respnsible Party Relatinship Signature

5 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I, have received a cpy f this ffice s Ntice f Privacy Practices. Please Print Name Signature FOR OFFICE USE ONLY We attempted t btain written acknwledgement f receipt f ur Ntice f Privacy Practices, but acknwledgement culd nt be btained because: Individual refused t sign Cmmunicatin barriers prhibited btaining the acknwledgement An emergency situatin prevented us frm btaining acknwledgement Other (Please Specify)

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