Office and Financial Policies Online Form

OFFICE AND FINANCIAL POLICIES FORM

PLEASE INITIAL EACH PARAGRAPH


As of 1/1/24 Allcare Therapy Services will be implementing a new cancellation policy to ensure continued therapy services for your child. We understand and acknowledge that family emergencies and illness do occur; however, we will be requiring 24 hour notice for all cancellations. If you are not able to give 24 hour notice due to illness or emergency, you will have 30 days to reschedule your missed session. If you do not reschedule your session, you will be charged a $30.00 late cancellation fee. Allcare Therapy Services requires a 90% attendance rate to ensure your child meets his/her goals. If your attendance falls below 90%, your time slot is not guaranteed. Allcare will assist you in finding a time slot that works better for you.

Payment Responsibility: I acknowledge full financial responsibility for service rendered by ALLCARE Therapy Services, LLC. I understand that I am responsible for prompt payment of any portion of the charges not covered by insurance, including co-insurance, deductibles and co-pays. I understand payment of co-pays is expected at time of service, as well as any prior balance I may owe. I understand my insurance carrier may not approve or reimburse medical services in full due to usual and customary rates, benefit exclusions, coverage limits, lack of authorization, medical necessity, or non-covered evaluations and treatment. I also understand that my insurance coverage depends on my contract with the insurance company.

Delinquent Accounts: I understand that my account may be turned over for collection and I will be responsible for all costs of collection monies owed, including court costs, collection and attorney fees. I further understand that if I fail to make any of the payments for which I am responsible in a timely manner, I will be charged a $35 late payment fee.

Attendance and Cancellations: I understand I need to keep a 90% attendance policy in order to maintain my recurring time slot. I understand that I am required to provide at least 24 hours advance notice if unable to keep a scheduled appointment. The scheduled time slot has been reserved exclusively for me and/or my family members. Repeated missed appointments may result in termination of therapy and/or change in recurrence of appointment time. I am financially responsible for the reserved appointment. If I cannot keep my appointment, I will be charged a $30.00 fee if proper notice is not given. The fee will be charged to my credit card on file. ALLCARE Therapy Services may make exceptions and waive the fee, at its discretion, for emergency or unusual circumstances. I understand that insurance companies do not provide reimbursement for cancelled sessions.

Referrals and Authorizations: I understand that, I am responsible to obtain all referrals from my Primary Care Physician (PCP) and keep track of how many visits were issued and when they expire. If authorization for office visits is required, I need to keep track of how many visits were issued and when they expire. Any services received
without a referral or proper authorization will be my responsibility.

Returned Check Fee: I, the undersigned, agree to pay a fee for any check returned by my financial institution regardless of reason.

Authorization to Release Information: I HEREBY AUTHORIZE ALLCARE Therapy Services to release medical information acquired in the course of my evaluation and/or treatment, to my insurance company, other physicians required to participate in my care, or to my child’s school district.

Allcare Therapy Services is an in-network provider with most major health insurance plans. We work directly with your insurance company.